Pediatric HIV- Current

update
Dr.Sanjeeva G N,
Professor, Dept of Pediatrics,
Indira Gandhi Institute of Child Health, Bangalore

Dec 2023
 HIV epidemic in India

• High Risk group

• General population
• Elimination of Pediatric
• High Burden
• Diagnosis HIV
• Universal treatment
• High mortality
• Chronic manageable
disease
Introduction
• Concept - U=U (undetectable = untransmittable)
• Strategy - Test and treat

• With various Mother to child transmission interventions, the risk of

transmission as well as pediatric incidence is diminishing.
• Because of effective ART, the HIV morbidity and mortality is
decreasing.
• Children born to HIV infected mother are vulnerable population.
Background

81,430 3.5% 10% 55%

Decline in
CLHIV in
CLHIV New CLHIV annual new
India
infections

National AIDS Control Organisation & ICMR-National Institute of Medical Statistics (2021). India HIV Estimates 2020: Technical Brief.
National summary of the HIV/AIDS epidemic in 2020

Image curtsey: National Guidelines for HIV Care and Treatment 2021
National AIDS Control Organisation & ICMR-National Institute of Medical Statistics (2021). India HIV Estimates 2020: Technical Brief.
 Rate of Mother-to-Child Transmission (including
breastfeeding phase) in India

5% 27.4% 40.2%
Target 2020 2010
rate

Mother-to-child-transmission (MTCT) accounts for over 90% of all HIV infections in children

National AIDS Control Organisation & ICMR-National Institute of Medical Statistics (2021). India HIV Estimates 2020: Technical Brief.
Risk of HIV transmission through PTCT with and
without any intervention

Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Towards universal access, Recommendations for public health approach – 2006 version – WHO
Image curtsey: National Guidelines for HIV Care and Treatment 2021
Four –prong Strategy for PPTCT

National Guidelines, India,8 2021c

Prevention of MTCT
• To all HIV infected pregnant mothers regardless of CD4 count and
Clinical staging

Tenofovir + Lamivudine + Dolutegravir (TLD)

• A viral load should be done at or after 32 weeks of pregnancy.

 Infant/children born to
HIV infected mothers

HIV infection status of infant/children

Unknown Infected Uninfected

HIV exposed HIV infected HIV affected

infant/children infant/children infant/children
Components of Care of HIV-Exposed Infant/Child

Immediate Infant
Care at Birth feeding
Follow up

Growth and Infant ARV

Development prophylaxis

Co-trimoxazole
prophylaxis Early infant
Immunization diagnosis

11
 Immediate Care at Birth- What’s
different?
oMinimise vaginal
examinations
oNon-invasive foetal
monitoring
oAvoid suctioning (If must,
<100 mm Hg pressure or Under the oWipe mouth and nostrils as soon
bulb suction) cover of as the head is delivered
Maternal
oAvoid milking of cord ART, there is
oCover cord with gloved hand and
oAvoid delayed cord no difference gauze before cutting
clamping in care and is Initiate feeding within
Universal similar to the 1st hour of birth
precautions for that given to according to the
Health Care uninfected
Providers
preferred and
mother
informed choice 12
 Infant Feeding Options

Exclusive Replacement
Breastfeeding Feeding

To be discussed in antenatal period

13
 Breast feeding Replacement feeding
Ideal
• Protect baby from many No HIV transmission
infections risk
• Less mortality, morbidity
• Increased bonding • No prolonged
• Is readily available, accessible, prophylaxis in absence
economic, does not require any of breastfeeding
preparation

Risk of other infections (GI,

HIV transmission Respiratory)
• More mortality, morbidity
• Requires prolonged • May not be readily available,
prophylaxis till 1 week after accessible, economic.
stopping breast feeding • Does require any preparation and
hence a good family support

Benefits versus Risks

Infant Feeding Options – in the first 6 months
of life
• Only breast milk
EBF: Exclusive Breast • No other food, fluid or water
Feeding • Drops or syrups consisting of vitamins, mineral
supplements, medicines or vaccines are permitted

ERF : Exclusive • Animal, Dairy milk, infant formula

Replacement Feeding • Hygienic, Katorie Spoon, No bottle feeds

• Breastfeeding and other foods or fluids such as animal

Mixed Feeding or formula milk given together during first six months of
life
Infant feeding - National Guidelines
for HIV exposed babies
• Exclusive breast feeding is recommended
feeding option of choice
• Avoid mixed feeding during 1st six months
of life
• When breast feeding is not feasible,
During first 6 months replacement feeding is advised only if all
of life six criteria are met
• Although EBF is still recommended
during first 6 months, practicing mixed
feeding is not a reason to stop breast-
feeding in the presence of ARV drugs.
14
Replacement feeding – six criteria

• Mothers known to be HIV-infected should give replacement feeding to

their infants only when ALL of the following conditions are met:
• Safe water and sanitation are assured at the household level and in the
community
• Reliably afford to provide sufficient and sustained replacement feeding (milk), to
support normal growth and development of the infant
• Prepare it frequently enough in a clean manner so that it is safe and carries a
low risk of diarrhoea and malnutrition
• First six months exclusively give replacement feeding
• Family is supportive of this practice
• Access health care that offers comprehensive child health services

17
Infant feeding - National Guidelines
for HIV exposed babies
• Breast-feeding can be stopped only after
baby is able to get a nutritionally
adequate and safe diet without breast
milk.
Breast feeding • Breast feeding continued along with
beyond 6 months complementary feeds till 2 years of age
regardless of infective status of the
infant.
• ART to the mother should be continued

14
High risk newborn
• Born to HIV infected mother not on ART
• Maternal viral load not done after 32 weeks of pregnancy
• Maternal viral load not suppressed after 32 weeks of pregnancy up to
delivery
• Mother newly identified as HIV +ve within six weeks of delivery
Infant ARV prophylaxis
 Infant prophylaxis
Low Risk Infants High Risk infants
1. Syrup Nevirapine or Options for dual prophylaxis:
2. Syrup Zidovudine# (in situations where Syrup Nevirapine + Syrup Zidovudine##
Nevirapine will not be effective): Duration of Dual ARV Prophylaxis:
• Mother with confirmed HIV-2 or HIV-1 • In case of Exclusive Replacement Feeding
and HIV-2 combined infections (ERF): From birth till 6 weeks of age
• Mother, who had received single dose of • In case of Exclusive Breastfeeding (EBF):
Nevirapine during earlier pregnancy or From birth till 12 weeks of age
delivery
• Mother who is on PI-based ART regimen
due to treatment failure
Duration of ARV prophylaxis: From birth till 6
weeks of age
Early infant diagnosis

Diagnosis of HIV Exposed Infants & Children

(<18 months of age)
 Early infant Diagnosis

• HIV-1 PCR test is performed in children less than 18 months.

• Maternal HIV antibodies passively transferred to the infant trans-placentally
• Can persist for nearly 9- 12 months in the infant (max- 18 months)
• Can result in false positive HIV antibody result in infants/children born to
HIV-infected mothers.
• Serological test for HIV, cannot be used reliably to diagnose HIV infection in
children less than 18 months.
 Diagnosis of HIV Exposed Infants &
Children (<18 months of age)
• Principles of testing
• HIV-1 PCR testing involves amplification of target viral nucleic acids (HIV RNA
and pro-viral DNA ) (99.0% sensitive and 98% specific)
• Window period for HIV-1 PCR is typically 6 weeks after last exposure
• Dried Blood Spots (DBS)/plasma are the specimens that can be used to
perform HIV-1 PCR testing.
• Two positive concordant virological test results required to confirm HIV
infection.
• After 6 months of life, HIV antibody test is used as screening test.
• HIV antibody tests at 18 months is the final confirmatory test.
EID protocol
HIV TNA PCR test at 6 Age more than 6 months
weeks of age HIV antibody serology test
- ve +ve - ve
+ve

Repeat HIV TNA PCR HIV TNA PCR

- ve
- ve +ve
Repeat HIV TNA PCR
- ve
Tie Breaker: Repeat HIV TNA PCR Not breastfed
+ve - ve in the last 3
Tie Breaker: months
+ve
Repeat HIV TNA PCR
+ve - ve
HIV -1 infection +ve
confirmed HIV -1 not infected
Immunization recommendation

More susceptible to infections and more likely to develop serious complications

Increased need for vaccination against all vaccine-preventable diseases

Live attenuated vaccines are contraindicated in severely immunocompromised

infants and children with HIV infection

All inactivated vaccines can be administered safely

All recommended childhood immunizations should be administered to HIV-

exposed infants as per National Immunization schedule
Important to
note
If not given at birth, should be delayed until ART has been started
BCG and the infant confirmed to be immunologically stable

• Should not be given to severely immunocompromised HIV-

infected children
Measles vaccine • Additional dose may be administered receiving ART following
immune reconstitution
• Recommended for use due to increased vulnerability to
Rotavirus vaccine diarrhoea
• Avoid in children with severe immunodeficiency.

Check for seroconversion and give boosters as required

Hepatitis B

Should be as per the national immunization schedule

Vitamin A
Co-trimoxazole Preventive Therapy (CPT)
• Co-trimoxazole preventive therapy (CPT) reduces the morbidity & mortality in
Children living with HIV
• CPT is effective in preventing life-threatening infections:
o Pneumocystis Jiroveci Pneumonia (Pneumocystis Pneumonia)
o Toxoplasmosis
o Certain bacterial Pneumonias
o Nocardiosis
o Diarrhoea due Enteric pathogens (Isosporiasis)
 All HIV-exposed infants/ children

From 6 weeks of age (or at first

encounter with health services)

HIV infection
HIV infection
reliably Confirmed
reliably excluded

Continue up to 5 years of age

WHO Stage 3 and 4 and/ • >5 years of age STOP

CD4 <350 cells/mm3 • WHO T-stage 1 or 2
• CD4 count of >350 cells/ mm3
on two occasions not less than 6
months apart

Continue
 Preparing the Family for “Lifelong ART”

What When How Who

WHO
WHEN
• Explain what
medicines will be Explain how the Identify who will
given • Specify when the medicines should administer the
WHA medicines should
HOW be taken/ medicines in
T• to do when the be given/ taken For ex: to set children and ill
child vomits or has reminder patients
to go outstation
ART Regimen
Confirm HIV infection: Virological / Serological Testing

Treat and stabilize acute condition and opportunistic infections

Baseline CD4 testing and other Lab investigations

Weight and Age of the Child

Age >10 years;

Age <10 years Weight > 30 kgs;
Weight <30kgs No renal disease

ABC+3TC+ DTG TDF+3TC+DTG

(ALD ) (TLD)
ART in ChildrenHIV-TB
withCoinfection
HIV-TB Coinfection
Patient’s
Timing of ART in relation to initiation of TB treatment
details
• Initiate Anti-TB treatment first
• ART should be started as soon as possible within two weeks of
CLHIV initiating TB treatment, regardless of CD4 cell count (except when
co-infected signs and symptoms of meningitis are present)
with TB • In CLHIV with TB meningitis, ART should be delayed at least four
weeks (and initiated within eight weeks) after treatment for TB
meningitis is initiated.
• Corticosteroids should be considered adjuvant treatment for TB
meningitis.
HIV-TB - Modifications of ART regimen

ART Regimen ART modifications while receiving rifampicin based regimen

DTG – based regimen Double the dose of DTG till 2 weeks after last dose of
rifampicin

LPV/r – based regimen Super boosting of lopinavir (LPV) with ritonavir (r) in the ratio
of LPV : r = 1:1

EFV – based regimen No modification required

Till 2 weeks after last dose of rifampicin

 Monitor of CLHIV after ART initiation

Clinical monitoring Laboratory monitoring to identify

 Clinical evaluation/overall wellbeing  ARV related toxicities
 Any new clinical event  Inter-current illnesses
 4S screening for TB  Drug-drug interactions
 Treatment adherence  Other metabolic abnormalities
 Adverse drug reactions

Immunological monitoring Viral load monitoring

CD4 testing Viral load testing
 Laboratory monitoring & follow up

At 6 months &
At 15 At 1 At 2 At 3
Tests Day 0 (baseline) 6 monthly
days month months months
thereafter
Yes Yes Yes
Hb / CBC Yes (if on (if on (if on Yes Yes
AZT) AZT) AZT)
Blood Urea Yes Yes
LFT/ALT Yes Yes
Urinalysis Yes Yes if on TDF
Yes
Creatinine (If planning to Yes if on TDF
start TDF)
Yes (if planning
Lipid profile Yes if on PI
for PI)
Random Blood Yes (If planning Yes (if on PI &
sugar for PI/DTG) DTG)
CD 4 % or
Yes Yes
counts
Screening for
Yes Yes Yes Yes Yes Yes
TB
First 6 months after starting ART are
critical
• May suffer from new events:
• Opportunistic infections

• IRIS

• ART related adverse effects

• New behaviour & life style patterns being set

• Rapid gain in weight, especially if the child was malnourished earlier

• Chances of misunderstanding/doctor shopping/alternative treatment …

• Most mortality in CLHIV occurs before/within few months of staring ART or else after
treatment failure/discontinuation
Definitions of treatment failure in children

Type of failure Defining factors

Virological Viral load >= 1000 copies/ml : On ART for at least 6 months
failure

Immunological Children between 12 and 35 months

failure *  CD4 - below 15 % &/ below 200 cells/ mm 3
Children between 36 and 59 months:
 CD4 - below 10 % &/ below 200cells/mm3
Children aged 5 years and above: At least one of the following 3 criteria
 Fall of CD4 count to pre-therapy level
 50% fall from peak 'on treatment' level
 Persistent CD4 levels below 100 cells / mm3 after 12 months of ART

Clinical  New or recurrent WHO stage 4 condition, after at least 6 months of ART
failure#  Progressive neuro developmental deteriorating
 Growth failure
 Adherence Monitoring in CLHIV
• Paediatric ARV options are limited hence ongoing adherence
monitoring is essential for CLHIV to remain on first-line regimen for
as long as possible

• Poor adherence plays a significant role in the emergence of drug

resistance and subsequent treatment failure

• Ensure checking for treatment adherence, and clinical monitoring at

every visit essential

• Barriers to adherence should be assessed and addressed regularly

Conclusion
• With rapid declining in the mother to child transmission,
elimination of pediatric HIV is reality.
• With the availability of more effective drugs – management
has become more simple.
• With U=U strategy, the risk of transmission has significantly
reduced.
• Future may include long acting drugs, drug holidays and
possibly cure.
Thank You