Pediatric HIV

Pediatric HIV - Tiny Targets, Big Battle

• Epidemiology (India): Primarily vertical transmission (mother-to-child).
  • Accounts for >90% of pediatric cases.
  • Risk: 15-45% without intervention; <1-2% with effective ART.
• Transmission Routes:
  • Intrauterine (in utero)
  • Intrapartum (during delivery)
  • Postpartum (breastfeeding)
• Diagnosis:
  • Infants <18 months: HIV DNA/RNA PCR (antibody tests unreliable due to maternal Ab).
    • Two positive virological tests confirm infection.
  • Children >18 months: ELISA/Rapid antibody tests, confirmed by Western Blot (like adults).

⭐ Early diagnosis is critical: Virological testing (HIV DNA PCR) should be done at 4-6 weeks of age for exposed infants.

• Clinical Staging: WHO clinical staging (1-4) adapted for children.
• Prevention of Parent-to-Child Transmission (PPTCT): Key strategy.
  • Antiretroviral therapy (ART) for mother & infant.
  • Safe delivery practices.
  • Safe infant feeding counseling (exclusive breastfeeding with maternal ART or exclusive replacement feeding).

Diagnosis in Kids - Spotting the Shadow

• Age dictates test choice:
  • <18 months: Maternal IgG Ab interferes. Use Virological tests.
  • >18 months: HIV Antibody tests (similar to adults).
• Virological Tests (Infants <18m):
  • HIV DNA PCR: Detects proviral DNA. Preferred.
  • HIV RNA PCR (Viral Load): Detects viral RNA.
  • Timing: Birth (high-risk), 14-21 days, 1-2 months, 4-6 months.
• Antibody Tests (Children >18m):
  • Screening: ELISA / Rapid tests.
  • Confirmatory: Western Blot / IFA.
  • Maternal Ab usually wanes by 12-18 months.
• Presumptive Diagnosis:
  • Symptomatic infant <18 months + 1 positive virological test → early ART.
• Definitive Exclusion (non-breastfed):
  • Two negative virological tests (one at ≥1 month, one at ≥4 months).
  • OR Negative Ab test at ≥18 months.
• Breastfed infants: Test 6 weeks after breastfeeding cessation.

⭐ For infants <18 months, two positive virological assays (HIV DNA PCR or RNA PCR) on separate blood samples are required for definitive HIV diagnosis.

Clinical Picture & Staging - Symptoms & Signals

• Common Presentations:
  • Failure to thrive (FTT), Persistent Generalized Lymphadenopathy (PGL), Hepatosplenomegaly (HSM)
  • Recurrent infections (e.g., otitis media, pneumonia, oral thrush)
  • Developmental delay
• WHO Clinical Staging (Key Features):
  • Stage 1: Asymptomatic, PGL.
  • Stage 2: Moderate unexplained malnutrition, recurrent URTIs, popular pruritic eruptions, angular cheilitis.

    ⭐ Persistent oral thrush (post-neonatal) is a key WHO Stage 2/3 indicator.

  • Stage 3: Severe unexplained malnutrition, chronic diarrhea/fever (>1mo), persistent oral candidiasis, pulmonary TB, severe bacterial infections.
  • Stage 4: HIV wasting syndrome, Pneumocystis jirovecii pneumonia (PJP), esophageal candidiasis, extrapulmonary TB, Kaposi sarcoma, HIV encephalopathy.
• Severe Immunodeficiency (CD4 Thresholds for initiating ART regardless of clinical stage):
  • <12 months: <750 cells/mm³ or <15%
  • 12-35 months: <500 cells/mm³ or <15%
  • 36-59 months: <350 cells/mm³ or <15%
  • ≥5 years: <200 cells/mm³ or <15%

ART & Prevention Power-Up - Fighting Back & Future Proofing

• ART Initiation: Treat ALL HIV-infected children immediately, irrespective of CD4/clinical stage.
  • ART Goals: Suppress VL, ↑CD4, ↓morbidity/mortality.
  • Infants/Young Children (<3yrs or <10kg): ABC + 3TC + LPV/r (or DTG).
  • Older Children (≥3yrs & ≥10kg): ABC + 3TC + DTG (or EFV).
  • Adolescents (≥10yrs & ≥35kg): TDF + 3TC (or FTC) + DTG.
• PPTCT (Prevention of Parent-to-Child Transmission): Key to an AIDS-free generation.
  • Maternal ART is crucial.
  • Infant ARV Prophylaxis:
    • Low-risk (mom VL suppressed): NVP daily for 6 weeks.
    • High-risk (mom high VL/unknown): Triple ARV for 6-12 weeks.

⭐ All infants born to HIV-infected mothers should receive ARV prophylaxis, ideally within 6-12 hours of birth.

• Breastfeeding: Encouraged with maternal ART & infant prophylaxis.

High‑Yield Points - ⚡ Biggest Takeaways

• Vertical transmission (MTCT) is the predominant route of pediatric HIV.
• Early diagnosis via HIV DNA/RNA PCR by 4-6 weeks; antibody tests unreliable early.
• Prophylaxis for Pneumocystis jirovecii pneumonia (PJP) is critical.
• Lifelong Antiretroviral Therapy (ART) should be initiated immediately in all infected children.
• Key clinical features: failure to thrive, recurrent infections, developmental delay.
• ARV prophylaxis for all HIV-exposed infants is essential (e.g., Nevirapine/Zidovudine).