HIV exposed Infants NACO 2023.pptx .imprtant points

Hiv

1. Management of HIV-Exposed Infants and Children & Early infant Diagnosis

2. Objectives By the end of the session participants would be able to understand: Definition of HIV exposed infants Components of care of HIV exposed infants and children Diagnosis of HIV infection (<18 months of age) Follow up protocol in HIV exposed infants

3. Who is an “HIV exposed infant/child” ? “HIV exposed infant/child” : Infants and children born to mothers infected with HIV, until HIV infection can be reliably excluded or confirmed in them n e year) Child: One year and above Infant : Under 12 months (one year), Child : One year and above

4. Why are HIV exposed infants a vulnerable group? Regardless of their own HIV status , HIV exposed infants are at a high risk of - malnutrition, - growth failure, - developmental delay and - repeated infectious disease by common and unusual organisms HIV infected infants frequently present with clinical symptoms in the first year of life HIV disease progresses very rapidly in young children, especially in the first few months of life, often leading to death Without care and treatment, 1/3rd of infected infants will die in the 1st year & 50% of children by 2 nd year of life 4 Important to engage and retain HIV exposed infants in care

5. Challenges to Care If HIV exposure not detected before birth, subsequent detection only when child is very sick Many HIV infected infants will die before HIV infection is suspected/ diagnosed Those detected suffer from severe morbidity & malnutrition leading to high mortality even if detected & treatment initiated It is critical to detect HIV infection during pregnancy and to follow up these infants to give them the best possible chance of HIV free survival

6. Components of Care of HIV-exposed Infant/Child Immediate Care at Birth Infant feeding ARV prophylaxis Early Infant Diagnosis Immunization and Vitamin-A Supplementation Co-trimoxazole preventive therapy(CPT) Assessment of Growth and Development Regular Follow up

7. 1: Immediate Care at Birth DONT’S Avoid multiple vaginal examinations Avoid invasive foetal monitoring Avoid suctioning (If must, <100 mm Hg pressure or bulb suction) Avoid milking of cord DO’S Wipe mouth and nostrils as soon as the head is delivered Cover cord with gloved hand and gauze before cutting Cord clamping soon after birth Initiate feeding within the 1 st hour of birth according to the preferred and informed choice of the parents Universal precautions for Health Care Providers 7 Under the cover of Maternal ART, there is no difference in care given at birth and is similar to that given to uninfected mothers & their babies

8. 8 To be discussed in antenatal period Health care providers and counselors should help the parents in reaching the right decision and support them in implementing their preferred choice Type of Feeding Definition EBF: Exclusive Breast Feeding Only breast milk No other food, fluid or water Drops or syrups consisting of vitamins, mineral supplements, medicines or vaccines are permitted ERF : Exclusive Replacement Feeding No breastfeeding Animal, Dairy milk, infant formula Hygienic preparation Feed by Bowl and Spoon, No bottle feeding Mixed Feeding Breastfeeding + other foods or fluids such as animal or formula milk during first six months of life. Mixed feeding increases the risk of transmission of HIV and should be avoided 2: Infant Feeding Options

9. Breast feeding Replacement feeding Infant Feeding Options

10. Infant feeding - National Guidelines for HIV exposed babies

11. Infant feeding - National Guidelines for HIV exposed babies

12. Complementary feeding Introduce complementary foods at 6 months of age while continuing to breast feed Start with small amounts of food, while maintaining frequent breast feeding Gradually increase food consistency and variety as the infant grows older, Feed a variety of nutrient-rich and energy-dense food from the family pot Use iron rich complementary foods or vitamin-mineral supplements for the infant, as needed Practise responsive (active) feeding, applying the principles of psycho-social care, good hygiene and proper food handling

13. Immunization and vitamin A supplementation

14. Immunization in infants and children living with HIV More susceptible to infections and more likely to develop serious complications Increased need for vaccination against all vaccine-preventable diseases All recommended childhood immunizations should be administered to HIV-exposed infants All inactivated vaccines can be administered safely Live attenuated vaccines are contraindicated in severely immunocompromised infants and children with HIV infection

15. Current national immunization schedule *In endemic districts only **One dose if previously vaccinated within 3 years # Being introduced in a phased manner in different states BCG; Bacillus Calmette-Guerin; DPT: Diphtheria-Pertussis-Tetanus; Hep B: Hepatitis B; Pentavalent vaccine: DPT+ HepB + Hib ( Haemophilus influenza type b); JE: Japanese encephalitis: MR: Measles–Rubella; OPV: Oral Polio Vaccine; TT: Tetanus Toxoid; IPV: Inactivated Poliovirus Vaccine; FlPV : Fractional Inactivated Polio Vaccine; RVV: Rotavirus Vaccine, Td: tetanus, reduced dose diphtheria

16. Important to note If not given at birth, should be delayed until ART has been started and the infant confirmed to be immunologically stable BCG Should not be given to severely immunocompromised HIV-infected infants, children, adolescents and young adults Additional dose may be administered receiving ART following immune reconstitution Measles vaccine Recommended for use due to vulnerability of HEI to diarrhoea should not be given in children with known severe immunodeficiency. Rotavirus vaccine C heck for seroconversion and give boosters as required Hepatitis B Should be as per the national immunization schedule Vitamin A

17. Growth and Development

18. History and physical examination Use of growth charts WHO Weight for age & length for age charts for girls & boys (0-2yrs) Identifying child at risk of malnutrition History (Ask); Physical Examination (Look & Feel) Assess growth according to: Signs (wasting, bipedal oedema, weight for height) Other nutritional deficiencies Growth and Nutritional Evaluation

19. Growth monitoring Weight - every visit to the ART centre Length - 3 monthly Plot them Weight and Length on WHO growth reference standards Early identification in case of faltering - Intensify assessment for HIV related features Nutritional deficiency chronic infections eg. respiratory , gastro-intestinal, UTI and TB ** Please refer to the weight for age, height for age, weight for height charts in the white card and fill during the visits

20. Patterns Observed on Serial Plotting on Weight-for-age Chart If the child’s growth curve is flattening: Intensify assessment for HIV related features Screen for nutritional deficiency Check for chronic infections such as respiratory, gastro-intestinal, urinary tract infection and TB , UTI Child with growth faltering should be immediately referred to a Paediatrician for further evaluation

21. Developmental Assessment Abnormal development raises concerns of HIV encephalopathy Developmental assessment at each visit includes assessment of: Motor / Fine motor Language Social skills Red Flag Signs (If the child cannot perform the following activities, it indicates developmental delay) Sit unsupported by 12 months Walk by 18 months (check creatine kinase urgently) Childs walk other than on tiptoes Run by 2.5 years Hold object placed in hand by 5 months* Reach for objects by 6 months* * corrected for gestation in case of preterm babies If milestones are delayed – refer to Pediatrician

22. Developmental Assessment 22 To use this chart, keep a pencil vertically on the age of the child. All milestones falling to left of the pencil should have been achieved. Examples shown are for ages 4 months and 7 months

23. Infant ARV prophylaxis

24. Early infant Diagnosis: Diagnosis of HIV Exposed Infants & Children (<18 months of age)

25. Diagnosis of HIV Exposed Infants & Children (<18 months of age) Maternal HIV antibodies get transmitted to the infant trans- placentally & persist for nearly 9- 12 months in the infant Occasionally, they may persist for as long as 18 months Children born to HIV-infected mothers will test positive for HIV antibodies regardless of their own infection status, due to presence of maternal anti-bodies. Positive HIV antibody (Ab) test thus indicates there has been exposure to HIV: DOES NOT mean infant/child is infected. Serological test for HIV, cannot be used reliably to diagnose HIV infection in children less than 18 months. HIV-1 PCR test is performed in children less than 18 months

26. Diagnosis of HIV by HIV-1 PCR Test HIV-1 PCR testing involves amplification of target viral nucleic acids (HIV RNA and pro-viral DNA ) The HIV-1 PCR test is: 99.0% sensitive 98%* specific (*which means that a confirmatory test is critical to eliminate the rare cases of false positives) 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

27. EID protocol The first HIV TNA PCR test for HIV-1 infection at 6 weeks of age ( and before 6 months). If positive, the test is repeated on another DBS sample as early as possible for confirmation If negative, screen for HIV antibodies (rapid test) at 6 months of age* if serology for HIV is positive, retest with a PCR test If negative, repeat HIV antibody test after 3 months of complete cessation of breastfeeding If the infant is seen for the first time after 6 months of age , an HIV antibody is performed if serology for HIV is positive, a PCR on a DBS sample is performed if in a HIV-exposed child older than 6 months of age HIV antibody test is negative If not breastfed in the last 3 months, probably not infected does not need HIV TNA PCR testing. * TNA PCR can be repeated earlier if the infant becomes symptomatic.

28. National testing algorithm for HIV-1 exposed infants and children <18 Months of age

29. EID : Universal Advisory for all exposed infants/children Counsel mother to maintain strict adherence to ART CPT to be initiated for all HIV exposed babies from 6 weeks of age and continued until proven HIV negative on all three serological tests at 18 months of age or later Continue babies on exclusive breastfeeding till 6 months of age and add complementary food after 6 months of age For babies on Exclusive Replacement Feeding, continue the same and add complementary food after 6 months of age Babies diagnosed HIV positive to be linked immediately to ART centre for ART initiation In cases of SerologicaI Discordance at 18 months, continue ART and follow the algorithm for management of babies with sero -discordance at 18 months 29

30. If child found HIV-1 infected, Follow Advisory 2: Continue cotrimoxazole till 5 years of age Manage Opportunistic Infections, if any present Start DTG 10mg based ART, regardless of CD4 % or count Initiate complementary feeding after 6 months of age Encourage breastfeeding till 24 months or beyond Test for HIV antibody for definitive diagnosis using all 3 serological tests at 18 months of age at ICTC EID Algorithm Advisory-1 and 2 Advisory-1 Start Cotrimoxazole preventive therapy , if not already started Encourage exclusive breastfeeding for all babies till 6 months of age If age more than 6 months, start complementary feeding along with breast milk

31. EID Algorithm Advisory-3 Repeat testing from "B" at 6 months and 12 months of age or 3 months after cessation of breastfeeding whichever is earlier If signs and symptoms of HIV infection develop at more than 6 months of age, follow the testing algorithm from "B" again Continue CPT until proven negative by all three antibody tests at 18 months of age or later If breastfed, encourage breastfeeding, till 24 months or beyond Counsel mother to maintain strict adherence to ART Test for HIV antibody, for definitive diagnosis using all 3 serological tests at 18 months of age or 3 months after cessation of breast feeding whichever later

32. National testing algorithm for HIV-1 exposed children >18 months

33. National testing algorithm for HIV-1 exposed children >18 months

34. Clinical criteria for presumptive diagnosis of severe HIV disease in infants and children < 18 months r equiring ART in situations where virological testing is not immediately available/report is pending Integrated Management of Childhood Illness. 2014.WHO

35. Follow-up protocol of HIV exposed infant (summary)

36. Case scenario 4-month-old male baby was born to HIV positive mother and presented to ICTC for HIV testing as advised during delivery. His parents are on ART. ICTC LT collected a DBS sample and sent it for testing, which was found to be positive for HIV-1. He was followed up and a second sample of DBS was collected and sent for testing 4 weeks later. The second sample also turned positive for HIV-1. The baby was referred to the ART centre for further management. Currently baby is in his 6 th month. Q1: Should ART be initiated for this baby? Q2: What are the next steps for managing this baby?

37. Case scenario- Answers Yes, ART should be initiated on DTG 10mg based regimen, based on the weight Start cotrimoxazole prophylaxis, if not already started, and continue till 5 years of age. Manage OI, if any present Initiate complementary feeding after 6 months of age. Encourage breastfeeding till 24 months or beyond Test for HIV antibodies for definitive diagnosis using all 3 serological tests at 18 months of age at ICTC

38. Key points HIV exposed infants/children need early engagement & structured follow up care The NACO early infant diagnosis algorithm should be followed for timely detection of HIV infection in the exposed infant TNA PCR is the test of choice for diagnosis of HIV infection in children below 18 months of age Ensure growth monitoring, timely immunization and age appropriate nutritional counseling CPT r educes morbidity and mortality in HIV-exposed /infected children If the baby is found to be HIV infected at any stage, ART should be initiated, and CPT should be continued until 5 years of age

39. Thank You