CARE OF EXPOSED - NEW

BORNTópico: Cuidados a um

recém-nascido exposto

Where would you prefer to be right now?

Mauritius resort? Attending a workshop?

Cuidados a um recém-nascido

exposto

• História: Uma menina infantil foi internada em uma unidade de internação pediátrica pela primeira vez aos cinco meses de idade. A criança tinha doença diarréica e em estado de choque. Ela nasceu por parto normal. Um programa de PMTCT não foi disponível a sua mãe.

• Resultados laboratoriais: A hemoglobina foi de 9 gramas por decilitro. Não havia teste de PCR disponível, mas um teste de anticorpo contra o HIV (ELISA) era positivo. Sua mãe testou HIV positivo.

• Diagnósticos clínicos de HIV/AIDS e anemia de deficiência de ferro foram feitos no momento.

• A criança estava abaixo do peso para a idade (abaixo do percentil 3) no momento. Durante os 6 meses seguintes, a criança foi admitida mais 4 vezes, com diarréia e com pneumonia

• Exame físico: Durante o ano seguinte, observou-se que a criança permaneceu magra, com linfadenopatia generalizada. Havia uma erupção cutânea impetiginizada de pele sobre ambas as pernas de vez em quando. Não houve hepatomegalia ou esplenomegalia. O ganho de peso foi fraco e o peso para a idade permaneceu abaixo do terceiro percentil.

• A criança foi vista mensalmente em serviços de pacientes externos e recebeu o suplemento macronutritivo na forma de leite Pelargon e cereal de arroz. O peso permaneceu abaixo do terceiro percentil. Os micronutrimentos foram fornecidos, na forma da Vitamina A 200 000 IU cada 6 meses, Zinco (10 mgs diariamente) e xarope de multivitamina. Ela recebeu o suplemento de ferro. Ela recebeu a profilaxia Bactrim. A terapia de Anti-retroviral não foi disponível

• A quinta admissão da criança foi após ingestão de parafina, cerca de três meses após a última admissão para diarréia. Havia sinais de dificuldade respiratória, mas estes foram resolvidos durante um período de cinco dias. O peso da criança tinha aumentado e o peso para a idade estava agora no percentil 10.

• A criança não teve mais admissões hospitalares. Ela continuou ganhando o peso e seu gráfico altura-por-idade cruzou o percentil 50 aos 18 meses de idade.

• Uma repetição do teste de anticorpos para HIV ELISA nesse momento foi negativo.

Questões:

1. Em que estágio clínico você colocaria essa criança antes que os resultados finais fossem obtidos? Qual é o seu critério de classificação?

2. Que erros diagnósticos foram cometidos neste cenário?

3. Porquê essa criança não conseguia desenvolver-se?

4. Porquê esse bebê HIV-negativo apresentou uma história sugerindo infecção pelo HIV?

By The End Of This Session You

Will be Expected to understand the following …

� Understand care of HEU Infant

� Understand different risk factors faced by HEU babies vs. HU babies

� Postpartum Care / management of Exposed Infant

� Routine Follow up of HEU Infant

� Growth Monitoring

� IPT in HEU Newborn

� Management of TB Exposed HEU newborn

HIV Exposed Uninfected Newborn

• Despite escaping HIV infection, HEU (HIV

Exposed Uninfected) children bear

consequences of being born to an HIV-

infected mother.

• Higher vulnerability to infectious diseases

during infancy

• HEU children experience more challenges

than HIV unexposed (HU) children

Overall Infant Risk Factors

Specific Disease Spectrum observed

in HEU Children

• Greater severity of common childhood infections, particularly pneumonia, B streptococcus and invasive pneumococcal disease.

• Growth and neurodevelopmental consequences of in utero exposure to some ARVs

• Increases risk for congenital cytomegalovirus (CMV) and it is important to be alert to the potential delayed neurologic sequelae of congenital CMV such as hearing impairment and neurodevelopmental delay.

• Commence life with lower levels of maternally derived antibody than HU infants.

• Respond robustly to vaccination – Must receive timeous administration of all routine infant vaccinations according to national schedules

• High rates of TB exposure in the home, with 10% of HEU infants already exposed to TB by three to four months of age in a South African study.

• Primary isoniazid preventive therapy in the absence of a known TB contact however did not reduce the risk of TB infection or disease in HEU infants.

CARE OF EXPOSED UN-INFECTED NEW BORN

Post-exposure prophylaxis

Infant regimens (WHO Recommendations )

Mother on lifelong

TARV

NVP at birth and

then daily for 6

weeks irrespective

of infant feeding

choice

If MOM DID NOT

GET FDC

(TDF/FTC/EFV)

TIMEOUSLY

(<4weeks to

delivery)

NVP + AZT (Dual

Therapy) at birth

and then daily for

12 weeks (AZT

stopped at 6 weeks.

NVP continued till

12 weeks )

If formula fed baby

can stop NVP + AZT

at 6 weeks

Post-exposure prophylaxis

Infant Regimens

Mother did not get

any ARV before or

during delivery

NVP + AZT as soon

as possible and daily

for 12 weeks (AZT

for 7 Days till PCR

results received )

Urgently) assess

whether mother

needs ART

Unknown maternal

status, orphan or

abandoned

Give immediate NVP

if baby is HIV

antibody positive (

i.e. HIV exposed )

Do PCR immediately

Follow up 10 week

HIV DNA PCR

Prophylactic nevirapine for HIV-exposed

infants

Age or weight Nevirapine

Birth – 6 weeks

< 2.5 kg 10mg/day

≥ 2.5 kg 15mg/day

> 6 week – 6 months 20mg/day

6 months – 9 months 30mg/day

> 9 months until breastfeeding

stops

Follow up of the HIV-exposed infant• HIV-exposed infants need close follow up:

– 3 days – Monthly for first 6 months– 3 monthly until HIV status determined

• Streamline this with CCR visits :• 3 days• 4-6 weeks• 10 weeks• 14 weeks• Monthly thereafter

Follow up schedule

3 days Did infant get PEP? If not, give it now

Check for jaundice, growth, general condition

Assess feeding

Educate on Importance of Attending CCR and Testing Baby

4 weeks – 6weeks IMCI assessment: Infection? Growth, Feeding

Immunize

Start co-trimoxazole

Stop NVP

Moz (PCR ) - WHO does not recommend this why ?

10 weeks HIV PCR test result and counselling

•HIV positive: do CD4 and Confirmatory PCR, continue CTX

• stop NVP and initiate ART

•HIV negative stop CTX if formula fed

IMCI assessment

Immunize

Care of Newborn & Infant

Follow-up care of infant

• Assessment of infant or young child growth and development

• Assessment and support of infant or young child feeding

• Assessment of mother’s coping

• Assessment of signs and symptoms of HIV-related conditions and clinical features of AIDS

• Routine immunizations

• Counselling (for mother) according to identified needs

• Referrals for mother and child

• HIV testing (PCR testing at four to six weeks of age and HIV antibody testing at 18 months)

18

Guidance on Infant Feeding

• Discussions about infant feeding especially important in early months of life and during special high-risk periods:

– Child is sick

– Mother returns to work

– Mother decides to change feeding methods

Mother knows she is feeding baby adequately when:

• Baby gains weight

• Baby urinates 6 to 8 times in 24-hour period

• Baby had at least 2 to 5 bowel movements in a 24-hour period

19

Ongoing Care

Immunization

Dentists

Growth monitoring Dietary advice

Counselling& support

Prophylaxis

Vitamin A Vermifugemmmmmmmm

mmmmm

• Vitamin A

Non-breastfed infants 0-5 months, 50 000 IU, a single dose at the age of 6 weeks.

All infants 6-11 months, 100 000 IU, single dose at 6-11months (preferably at 9 months when child comes for immunization).

All children 1-5 years, 200 000 IU, single dose at 12 months and every 6 months until the age of 5 years.

Vitamin A Supplementation (continued)

• Children with persistent diarrhoea, measles,

severe malnutrition and xerophthalmia should

receive treatment dose of vitamin A even if

they received vitamin A supplement within the

past 6 months. .

22

Promote Health through Follow-Up

Each visit with HCW should include:

• Assess and manage for common illnesses

• Identify non-specific symptoms / conditions related to HIV infection

• Provide HIV testing

• Provide micronutrient supplementation, nutrition education and support including information on food hygiene and fortified foods

• Provide Cotrimoxazole

• Assess clinical features suggestive of HIV .

23

Promote Health through Follow-Up (continued)

Promote health and prevention of illness– Assess and support the mother's infant-feeding

choice.

– Infants who fail to grow require special attention.

– Underlying infections should be diagnosed and treated promptly.

– Monitor growth and assess causes of growth failure, if observed

– Immunize according to the guidelines

– Screen for TB and treat if indicated.

– Offer malaria treatment and prophylaxis

– Treat anaemia as indicated

24

Growth Monitoring

• Growth-monitoring programmes focus on foetal growth and child growth in first five years of life.

• Conditions related to weight loss are underlying infection, acute diarrhoea and HIV-related growth failure.

Growth indicators

• Weight for age is useful for detecting the sum total of nutritional experiences the child has had.

• Weight for height is a useful measure of acute malnutrition.

• Height for age is useful for detecting chronic malnutrition and helps identify stunted growth in children.

• Head circumference is useful during the first two years and is a measure of brain growth - Helps identify Encephalopathy

25

Isoniazid Preventive Therapy

• Babies born to mothers with smear-positive

PTB should be given isoniazid.

– 5mg/kg daily for 6 months

• After 6 months child is vaccinated with BCG.

• Breast feeding is safe

• If child develops symptoms while on isoniazid

preventive therapy, must investigate for TB.

• If TB is diagnosed, isoniazid is stopped and anti-

TB treatment instituted.

Malawi PMTCT Training Package 26

Contact screening algorithm for children

Documented TB exposureClose contact with an adult or adolescent with pulmonary TB or child with smear-positive TB

Close contact is defined as any household contact or contact outside the household that is of sufficient duration and proximity to pose a high risk

of infection.

Are there any current symptoms or signs suspicious of TB?

Cough, wheeze, fever, lethargy, fatigue, weight loss, or visible mass in the neck

No current symptoms or signs Symptoms or signs present

<5yrs HIV negative or

HIV positive≥5yrs and

HIV-uninfected

Observe for symptoms Evaluate / refer if symptoms indicative of TB

INH for 6/12 No preventive therapy

Investigate for TB

No TB TB diagnosed

Persistent non-remitting symptoms

Child is well Treat for TBEnter into TB register

Follow up after 1-2 weeks

Refer to hospital

Dr ND NHLAPO

EARLY INFANT DIAGNOSIS & PAEDS HIV TESTING

• Some African Countries 1:3 women of child-bearing age is HIV-

infected

• HIV prevalence in women attending antenatal

Care is: 29%

• Without PMTCT interventions:

– 40% of infants will be HIV infected during pregnancy,

birth, and BF

• Of the infants infected, median survival is one year

• More than 50% of children infected with HIV

vertically will die by 2 years old with no intervention.

Overview

Because death and disability is high for

HIV-infected infants, every effort must

be undertaken to accurately diagnose

and initiate treatment as soon as possible.

Key strategies to optimise Paediatric HIV

outcomes

1) Prevention and Elimination of Mother To

Child Transmission (P/EMTCT)

2) Early Infant Diagnosis (EID)

3) Increased uptake of Co-trimoxazole

initiation

4) Early initiation of HAART in infants and children

PMTCT

• Successful in reducing transmission of

HIV from mother to child

• In Southern Africa , has reduced rate of MTCT

to 2.6% (2013 target 7.5%)

• Contributed to significant decrease (25%) in

infant mortality rate from 2009 – 2011

• Retention of pregnant women on ART

remains a challenge, roll out of option B+

• To be covered in detail elsewhere

1. INE. População projectada. Moçambique (1900–2040). Retrieved March 24,

2016, from: http://www.ine.gov.mz/

2. INSIDA 2009

3. UNAIDS Gap Report, 2014

4. Epidemiologic surveillance round 2011 (ronda de vigilância epidemiologica, 2011)

5. HIV National Program data, - presented in the HIV national meeting March 2016

Mozambique HIV Epidemic ProfileEstimated population (2014)1 24.3 million

Estimated HIV Prevalence (age 15 -49), 20092 11.5%

Number of people living with HIV (all ages), 20142 1,400,000

Women aged 15 and up living with HIV, 20143 830,000

Children aged 0 to 14 living with HIV, 20143 160,000

Deaths due to AIDS (all ages), 20143 45,000

Orphans due to AIDS (0-17), 20143 610,000

HIV prevalence in pregnant women, 20114 15%

ART coverage for eligible pop., 20155 84%

ART coverage for PLWHIV, 20155 51%

ART site coverage, 20155 63%

PMTCT coverage, 20155 94%

Overview

Early infant diagnosis

What test?

HOW WOULD YOU BEST

DEFINE :

“HIV EXPOSED BABY “ ?

HIV-EXPOSED INFANTS

• An HIV-exposed child is defined as a child born

to a mother living with HIV until HIV exposure

stops (6 weeks after the complete cessation of

breast feeding) and HIV infection can be excluded.

• HIV-exposure status should be determined

before birth as part of the PMTCT programme –

where the mother’s status is not known, this should be determined after birth

How to find Children with HIV• Screen for HIV exposure at all points of routine contact with infants and

children (i.e. EPI clinics)

– Rationale—lots of exposure to young infants (use as a safety net to capture

exposed infants LTFU from PMTCT cascade)

• Perform Routine Provider Initiated Testing & Counseling (PITC)

• in all areas where sick children are seen (OPD, malnutrition clinics/wards, TB

clinics/wards, in-patient wards)

– Rationale—infants and children with HIV who have not been tested get sick

when their immune system wanes

• Test high risk populations (children of HIV+ adults in care and treatment,

OVCs, key population youth)

– Rationale—these children/youth are high risk based on in-utero

exposure to HIV, possible parental loss due to HIV, or personal high risk

behaviors

40

HIV test used for diagnosis

• For adult and Children (From 9 months).

oDETERMINE;

oUNIGOLD for confirmation if determine is

positive.

• For Children under 9 months

o PCR DNA.

HIV ELISA or Rapid test

• Detects antibodies to the virus (not the virus!)

• Infants born to HIV-infected women test

POSITIVE – Maternal HIV antibodies cross the placenta

– Maternal HIV antibodies may last up to 18 months but

often disappear by 9 months of age

• Used to diagnose adults or children > 18 months

• Can be used to determine HIV exposure in

children < 18 months (< 9months in Moz )

These tests do not diagnose infection in children <18mo:

the mother’s antibodies may still be present

HIV Testing: HIV Antibody Tests

• Rapid tests are cheap, fast, simple, and accurate.

• Highly sensitive and specific – > 99.3%, > 98.6%

respectively

• May be positive in ALL infants of HIV-infected

mothers for up to 18 months because they will have

mom’s IgG, including infants that are not infected

= diagnose exposure only

• If it is necessary to diagnose HIV infection in an

infant less than 9- 18mo then order an HIV PCR test

• ALL HIV-exposed infants should get an ab test at

18mo

HIV Testing: HIV Antibody Tests

• CAUTION with using an Ab test in an infant who is 18mo and who is still breastfeeding

• A positive antibody test in a child >18mo who is BF means that the baby is HIV-infected.

– A negative antibody test in a child >18mo who is BF means that the infant is most likely HIV-negative but:

• Could be in the “window period” before an Ab test is

positive and so might not be HIV-negative

• Will need another Ab test 6 weeks after total

cessation of BF – might still be in the window period so use caution

44

1ST Test DETERMINE

POSITIVE

2nd Test UNIGOLD

Negative

INCONCLUSIVE

If maintain undetermined, make appointment for retest

after 4 weeks

In the following visit (2nd) repeat the Protocol and define the result in Visit

HIV Positive HIV Negative INCONCLUSIVE

Make appointment for new testing after 8 weeks to

collect blood specimen to be sent to a reference lab.

Positive

NEGATIVE

In 3rd Visit use the result from

reference Lab. If there is no result yet,

repeat the protocol if maintain

undermined report HIV Negative

Report HIV Negative

Report HIV Positive

Repeat

immediately

the protocol

Algorithm

HIV DNA PCR test• Detects virus in the baby’s cells

• A positive HIV PCR test means HIV infection

• Highly accurate but never 100% so interpret

together with clinical features; if diagnosis in

Doubt then follow infant up or retest

• Not the same as the viral load test (RNA PCR)

• Perform on all HIV-exposed at Birth and

10 weeks of age

• Repeat 6 weeks after breastfeeding stopped

HIV Diagnosis: Virological Tests

• HIV PCR – directly detects the HIV virus

by detecting its genome in human cells

• This is the “Gold Standard” for HIV testing

• Two types:

- HIV DNA PCR test

- HIV TNA PCR test

HIV TNA PCR

• Total Nucleic Acid: detects both HIV -1

proviral DNA and RNA

• Done either on EDTA or Dried Blood Spot

• Sensitivity rate reportedly between 98.8% -

99.7% (higher than DNA PCR)

• Adopted by National Health Laboratories , roll

out of v2 with higher sensitivity rate

HIV Diagnosis: Virological Tests

• Viral Load (VL) – detects HIV virus RNA

– Quantitative

– Used principally in monitoring response to

treatment

– No longer used for confirmation of

HIV infection in infants <18 months

Timing of PCR test• PCR at birth: Only detect those infected in

utero

• PCR from 2 weeks: Only detect those

infected in utero and perinatally

• So recommended age to pick up as many

babies as possible is > 4 weeks

• If breastfed - ongoing risk - need to repeat

when breastfeeding has stopped

Unknown maternal HIV status• Offer woman VCT. If she tests HIV positive,

test the infant, younger than 18 months of age,

with an HIV PCR.

• Need parental consent to do an HIV test on the

infant.

• Where parents are deceased, infant testing

should still be done on the consent of the primary

care giver

HIV DNA PCR• Sample:

- liquid blood in purple top (EDTA) tube or - dried blood spot (DBS)

• Both samples

- cost government the same price and - give equally accurate results

• Choice of sample depends on the skills ofhealthcare worker to obtain an unclotted sampleor 3 full blood spots

versus

VENOUS

CAPILLARY

BLOOD SAMPLING & COLLECTION

Dried Blood Spot

Collection and Handling

Procedure for DBS collection1. Warm the area

2. Put on gloves, wash hands

3. Position baby with foot down

4. Clean area, dry 30 sec

5. Press lancet into foot, prick

skin

6. Wipe away first drop

7.Allow large drop to collect

8.Touch blood drop to card

9. Fill entire circle with drop

10. Fill at least 2 circles

11. Clean foot, no bandage

1st choice

2nd choice

Foot hold & squeeze

Fill at least 2 circles

How to Package DBS for Storage

� At the end of each day, pack the dry DBS

(leave for next day if not dry 3 hrs)

� Put weighing paper between cards so they

can’t touch each other

� Insert into sealable plastic bag

� Add desiccant packet

� Press air out of bag

� Label bag and seal

� Put into refrigerator if not going to the lab that day

Dry Completely Before Packaging

Keep requisitions with DBS cards

Insert Into Sealable Plastic Bag

Collection Problems

DRIED BLOOD SPOT PUNCHES

ARE VOLUMETRIC MEASUREMENTS

DRIED BLOOD SPOT PUNCHES

ARE VOLUMETRIC MEASUREMENTS

Require the Same Accuracy and PrecisionRequire the Same Accuracy and Precision

EQUALSEQUALS

POTENTIAL ALIQUOT VARIABILITY

WITH DRIED-BLOOD SPOT SPECIMENS

=

10 µL 10 µL

≠≠≠≠6 mm punch 6 mm punch

1. Add Kit Diluent (150 uL, 1:30)

2. Cover plate, incubate overnight at 4oC

3. Shake plate gently to mix

4. Add Diluent to assay plate (125 uL)5. Transfer DBS eluate (25 uL) to assay plate

(1:150 final serum dilution)

Elution Plate Assay Plate

1. Cover plate, incubate plate 90 min at 37oC

2. Wash plate 4x

3. Add IgG-Enzyme Conjugate

4. Cover plate, incubate 30 min at 37oC

5. Add Substrate (150 uL)

6. Incubate 10 min at 25oC

7. Add Stop Solution (150 uL)

8. Read plate at 405 nm

Typical EIA Assay Procedure for Dried Blood

Spots

Punch 3 or 6 mm disks into microwell plate

65

HIV Exposed New-born (1 to 9 months old) in CRCHIV Exposed New-born (1 to 9 months old) in CRC

PCR HIV DNA (DBS)Negative

Maintain follow-up at CRCInfant/Child is infected.

(alta da CRC)

Immediately start ART.

Repeat DBS to confirm

infection

Infant/Child develops signs or

symptoms suggestive of HIV

Repeat PCR HIV DNA (DBS) and

send to clinical evaluation

If stopped the

breastfeeding long

than 2 months and

the infant without

signs or symptoms Negative

Discuss the

case with

clinicians

Inconclusive

Negative

Infant remain well and reaches 9

months of age

Conduct HIV antibody test between 9 to 18 months

of age

Negative

Repeat PCR HIV DNA

(DBS) to confirm the

diagnosis

Link the child with

care and treatment

to immediately start

ART

Positive

Positive

Positive

Report not

infected and alta

from CRC

Infant/Child is

infected. (alta da

CRC) Immediately

start ART. Repeat DBS

to confirm infection

if the infant

maintain

breastfeeding or

the test was

performed less

than 2 months

Infant remain in CRC follow-up and repeat

RDT at 18 months or 2 months after stop

breastfeeding

Positive

Positive

Negative

Infant HIV testing

PCR positive

DO a confirmatory PCR

Continue cotrimoxazole

Stop NVP and initiate HAART

Continue breastfeeding for 2 years

Exclusive breastfeeding + NVP daily for 6weeks .

If weaning will compromise the nutritional status of the child, then she should

continue to breastfeed for 2 years.

PCR negative

Collect and send DBS for DNA PCRAt birth and at 10 weeks immunization visit

Earlier if clinically indicated

If < 18 months

Continue cotrimoxazole

Repeat HIV PCR test 6 weeks after breastfeeding stops

HIV-exposed infant

67

Mother’s Status Action

Positive maternal HIV status All infants born to HIV-infected women require a PCR.

Negative maternal HIV status Rapid test should be offered to mother to ensure she has remained HIV-uninfected.

Unknown maternal HIV status Offer a rapid test to the mother. If she tests positive then her infant should have a PCR at the same visit. Provide the mother with the care she requires.

Unknown maternal HIV status and mother refuses testing

Offer an HIV rapid test (on the infant) to assess HIV-exposure. If the infant’s rapid test is positive, perform a PCR test on the infant during the visit and counsel the mother to seek further HIV testing and care. (Note in the RTHC so that mother receives continued support during infant follow-up)

Which test?

• Abandoned 3 month old baby, mother's

status and whereabouts unknown

• 6 weeks old HIV- exposed baby still

breastfeeding

• 20 month old baby, mother HIV positive

• 5 year old

Goga AE, et al SAPMTCTE 2010

Perinatal Transmission Down !

2,7% in 2011 but ….

Early Infant Diagnosis

Sherman et al, IAS 2012

• PCR tests increased from

3370 in 2003 to 293786 in

2011

• Percentage positivity

declined from 16.4% in 2006 to

2.8% in 2011

• Scaling up EID in Africa has been made possible not only by increasing the laboratory infrastructure but by circumventing the need for venesection

• In 2012: 75% samples arrive in dried blood format, Results are delivered bysms printer

Courtesy Sherman and Carmona

6 weeks PCR: TOO LATE and TOOEARLY

• Too late to prevent early mortality:– Unable to initiate HAART early enough (7 weeks of age) to

prevent ±20% early mortality by 13 weeks of age

– IU-infected infants (±20%) go undetected because of LTFU or death before 6-weeks

• Too early to detect all IP infections:– Maternal ARV and infant NVP delay detection of HIV at 6

weeks because of a low target of virus (esp on DBS) failing to detect 10-20% of early infections

• 6 weeks: miss up to ±30-40% of all early HIV+Courtesy Gayle Sherman

WHY WAIT 4-6 WEEKS TO PERFORM

ACCURATE PCR ?

EID in the context of PMTCT coverage• Infants are exposed to ART since before

they are born

• Studies: Duration of ART exposure

• influences the age at which HIV is

detected

Treatment with ART may reduce VL to

levels below PCR diagnostic threshold values

EID in the context of PMTCT

coverage

• TNA PCR sensitivity may drop to 83% for NVP

exposed infants

• 11% of HIV infected children had false

negative PCR due to ART prophylaxis in

one study

• Also affects infants breastfed by HIV +

mothers on ART

Haeri Mazanderani et al (2014); Shapiro et al (2013); Lilian et al (2011).

Positive HIV PCR results

• Baby is HIV infected

• Do a confirmatory PCR (<18 months)

• Pull other baseline bloods: CD4 count, VL,

FBC/Hb, Chol, TG

• Start ART ASAP

• Do not delay initiation of ART for results

• Note: neonates require referral to an experienced clinician, as do children weighing less than 3kg

Stigmata of HIV Infection

Stigmata of HIV Infection

83

Presumptive HIV infants/child

diagnosis

• Used for children under 18 months of age.

o If an infant/child with signs or symptoms

suggestive and/or social warning sign for HIV

undergo RDT´s and if positive should

immediately start ART.

o The diagnosis most be confirmed by PCR

DNA .

HIV-Exposed Infant Testing Schedule

>/18 months

• HIV Antibody test - 18 months old or greater.

– Rapid test for all HIV-exposed infants at 18mo

• result

– Infant is positive, confirm with another rapid test

• result, infant has not BF in last 6wks

– Infant is negative

• result, infant is still BF or has had BM less than

6wks prior to the test - infant could be in the “window

period” so a negative test does not rule out HIV infection.

– Repeat rapid test 6 wks after all BF has ceased.

– Continue Bactrim (and NVP if mom not stable on HAART)

Discordant and Indeterminate HIV Test

Results

• Less than 18-mo– HIV PCR + but negative/indeterminate repeat

HIV PCR or undetectable VL: repeat HIV PCR with VL

• Older than 18-mo– 1st rapid test (+) but second rapid test (-): send

ELISA

– If ELISA still discordant, perform PCR

• Indeterminate and discordant results after

testing as above: refer, do not delay access to

treatment by waiting to repeat the tests

Questions ??

We made it!