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All aspects of the health and emotional wellbeing of an HIV-positive child must be addressed, whether or not the child is receiving antiretroviral treatment. An enormous amount can be done for an HIV-infected child even if antiretroviral treatment is not available. The general management of all HIV-infected children is the same.
If HIV infection is excluded in an HIV-exposed child, the child should be referred to a well-child clinic and requires no further follow up for HIV infection. With the use of antiretroviral prophylaxis perinatally, most HIV-exposed infants will not be infected.
Every effort must be made to keep HIV-infected children at home with their family and to manage them at a local primary-care clinic. They should only be referred to a special HIV clinic or hospital if there are clear indications.
HIV-infected children should be managed at home if at all possible.
Ideally the community-based primary-care clinic should meet the needs of most HIV-positive children. This requires the integration of many different services (a ‘one-stop shop’). Care at a primary health clinic is usually provided by nurses and not doctors.
Children should always be seen as a member of a ‘family’ and not simply as an individual. Many of the health problems of children are a direct result of problems within the family (poverty, neglect, abuse, poor education). Therefore the management of any child must take into consideration the family and home environment. Family-centred care (or family-oriented care) is the care of a child as a member of a family. ‘Do not forget the family!’
Ideally the whole family should be cared for by the same staff at the same clinic.
Both HIV-positive and negative children should receive routine clinical care. This is provided at a local primary-care clinic. The ‘well-baby clinics’ and ‘under-5 clinics’ must be integrated into other health services such as maternal care, immunisation and managing sick children.
Routine care includes:
All infants born to HIV-positive mothers are at risk of being infected themselves with HIV. It is important to determine whether these HIV-exposed infants are HIV infected or not as soon as possible after birth. This is possible with PCR testing at six weeks after birth, in infants who have never been breastfed. Infants who have received breast milk should also be tested at six weeks. If the result is negative the test should be repeated at six weeks after their last feed of breast milk.
If the infant develops clinical signs of HIV infection before six weeks the infant should be tested with PCR immediately. If negative repeat the test at 6 weeks and again 6 weeks after the last breast feed. Similarly, any breast fed infant who develops clinical signs of HIV after the routine 6 week screen should be retested.
If PCR testing is not available, clinical features should be used to make a probable diagnosis. A rapid test should then be done at 18 months. Often rapid testing is also done at nine or 12 months as many uninfected children will already have a negative test by this time.
Once HIV infection has been excluded, these infants require only routine care at a well-baby clinic. However, until HIV infection has been excluded, HIV-exposed infants should be followed-up together with the HIV-infected infants.
Until HIV infection has been excluded, HIV-exposed infants must be closely followed:
It is safe to give most routine immunisations (Expanded Programme on Immunisation) to well HIV-exposed infants in the first months of life. Ideally, BCG should not be given to children known to be HIV infected. However, giving BCG to all infants after delivery, irrespective of their HIV status, is still recommended in countries where tuberculosis is common.
Other routine immunisations should be given to all HIV-infected children even if they have signs of HIV disease.
HIV-exposed newborn infants should receive routine immunisations.
Routine pneumococcal and rotavirus immunisation is being introduced in many countries where HIV infection is common, to reduce the frequency and severity of pneumonia and gastroenteritis in HIV-infected children.
Annual influenza immunization is recommended for all HIV infected children.
Most of the morbidity and mortality in HIV-infected children are due to HIV-associated infections. Primary prophylaxis is the use of antibiotics to prevent some of these infections. Therefore primary prophylaxis is an important part of healthcare during the asymptomatic phase of HIV infection.
Secondary prophylaxis is the use of antibiotics to prevent recurrences of HIV-associated infections, i.e. in children who have previously had that HIV-associated infection.
Primary prophylaxis is the use of antibiotics to prevent HIV-associated infections.
It is very effective in reducing illness and deaths due to Pneumocystis pneumonia and common bacterial infections. Pneumocystis pneumonia is the main cause of death in HIV-infected infants, especially infants under six months of age. Pneumocystis infection is particularly common in Africa.
The prophylactic use of co-trimoxazole is simple, cheap, well tolerated and lifesaving. It forms a very important part of the management of HIV-infected children and can halve the mortality from HIV-associated infections.
Co-trimoxazole prophylaxis forms a very important part of the management of HIV-infected children.
All HIV-infected infants should receive co-trimoxazole prophylaxis.
Children who have already had Pneumocystis pneumonia should remain on secondary co-trimoxazole prophylaxis until they are five years old.
Infants should be given co-trimoxazole syrup. Older children may be given single-strength tablets. WHO recommends a daily dose. The daily dose depends on the child’s weight.
|Weight band||Daily dose|
|< 5 kg||2.5 ml paediatric suspension|
|5–14 kg||5 ml paediatric suspension or 1/2 regular strength tablet|
|15–29 kg||10 ml paediatric suspension or 1 regular strength tablet|
|30 kg or more||2 regular strength tablets|
Side effects are uncommon in children. The commonest side effects are skin rashes, which usually occur in the first few weeks of treatment. These are usually mild erythematous rashes. However, they can be serious. Parents must stop the co-trimoxazole and bring the child to the clinic if the child develops a generalised, maculopapular rash, skin blisters or mouth ulcers, as these are the signs of serious hypersensitivity to the drug.
A careful watch should be made for a rash. Routine laboratory tests are not needed.
Children who have developed side effects to co-trimoxazole should be given dapsone instead. The dose of oral dapsone is 2 mg/kg daily up to an adult dose of 100 mg daily. A solution of crushed tablets are used. Unfortunately dapsone is not as effective as co-trimoxazole in preventing Pneumocystis pneumonia and it does not provide prophylaxis against other organisms.
If the side effects to co-trimoxazole are only moderate or severe (grade 2 or 3) the child can be referred to an antiretroviral centre for desensitisation with low doses of co-trimoxazole. Co-trimoxazole should never be given again after a potentially fatal (grade 4) reaction.
In all children, good nutrition plays an important role in helping to maintain the normal functioning of the immune system. In contrast, malnutrition (undernutrition) weakens the immune system. Therefore, poor nutrition is especially dangerous in HIV-infected children, placing them at even greater risk of HIV-associated infections. Unfortunately, children with HIV infection are often undernourished.
Good nutrition is an important part of managing children with HIV infection.
Always look carefully for missed infections in undernourished children (especially tuberculosis). Infections often lead to a rapid deterioration in the child’s nutritional state.
It is important that parents are aware of the importance of good nutrition and have the knowledge to give their children the correct foods. The nutritional value of meals can be improved by:
A balanced, mixed diet need not be expensive.
Vitamin A is important in maintaining a healthy immune system. All children with HIV infection should be given oral vitamin A supplements.
Although a standard paediatric multivitamin supplement 5 ml daily is often recommended, this has not been shown to be necessary unless the child is undernourished.
Zinc supplements (10 mg elemental zinc as zinc sulphate daily) from six months of age reduces morbidity from diarrhoea.
Yes. It is important to regularly deworm all young children, but especially children with HIV. Deworming every six months is recommended for children between the ages of two and five years in communities with poor hygiene and inadequate sanitation (poor toilet facilities). This should be done even if there is no history of roundworms in the stool. Medication is usually given at the local primary-care clinic or in schools. Deworming has been found to improve the learning capacity and growth of school children.
Mebendazole is the drug of choice. Albendazole is more expensive. Both these drugs are highly effective for roundworms. The dose for deworming is:
Dental care is important as dental caries are very common in children with HIV. Bad teeth may also reduce nutrition intake. Daily brushing of the teeth and restriction of sweetened food and drinks helps to keep the teeth healthy. Most children cannot brush their own teeth adequately until the age of seven years. Therefore, the caregiver should do the brushing with a gentle action, using a soft toothbrush. If the caregiver cannot afford toothpaste, salt may be used. Children with dental caries should be referred to a dentist for treatment.
Children who fail to thrive despite optimal medical treatment may require additional nutritional support. Ideally they should be assessed by a dietician. Additional protein and calorie intake should be considered up to 150% of the daily recommended allowance.
Although rest is important, children also need regular exercise to grow and develop normally. Most well HIV children can play sport normally. Play is important for all children.
It is essential that children with HIV mix with other children in play groups and at school. They should attend normal schools as they are not a risk to HIV-negative children.
Neurodevelopment as well as physical growth should be routinely monitored in all children, but especially children with HIV infection. Developmental milestones are used for the routine monitoring of neurodevelopment.
One of the first and most important clinical features of symptomatic HIV infection in children is a delay in developmental milestones. Children with advanced HIV disease may also have a slowing of head growth (head circumference).
All HIV-infected children who are not already on antiretroviral treatment must be seen regularly at the local primary-care clinic in order to monitor their clinical condition and staging. This is an important part of monitoring the progress of the disease. It is not practical to follow all HIV-positive children at a special HIV clinic.
All HIV-infected children who do not qualify for antiretroviral treatment (and HIV-exposed children where HIV infection has not yet been excluded) should be followed every six months.
This is based on general examination. Specific signs of HIV infection and HIV-associated infections must be looked for. A history of infection is also important. Usually special investigations are not needed to assess the clinical stage.
Clinical staging is an important part of routine follow up.
The CD4 percentage. The aim is to keep the CD4 percentage within the normal range (above 25%) for as long as possible. Capillary or venous blood has to be sampled for the CD4 measurement.
The CD4 percentage is used to monitor the child’s immune function.
In children who are well, and not yet on antiretroviral treatment, the CD4 percentage should be measured every six months to assess the condition of the immune system. Once the CD4 count falls to 25% or below, the child should be followed more closely.
All HIV-infected children below one year of age should be started on antiretroviral treatment.
There is no need to routinely measure the viral load in older children with HIV infection who are not yet on antiretroviral treatment.
Because HIV-infected children usually present clinically with an HIV-associated infection. These infections are often the final cause of death. Therefore it is vitally important that HIV-associated infections are detected and diagnosed as soon as possible so that early treatment can be started.
By taking a careful history and performing a good clinical examination at every follow-up visit. Important questions to ask (‘red flags’) are:
Important clinical signs are:
Any child with a suspected or obvious HIV-associated infection should be treated or referred immediately.
The WHO defines adolescence as young people between the ages of 10 and 19 years. Adolescence is the time of physical, emotional and psychosocial change from childhood to adulthood. Adolescents require special care as their needs are different from those of both children and adults. The first signs of puberty (breast buds, testicular enlargement and pubic hair) usually indicate that the child should be regarded as an adolescent.
Adolescence is the time of physical, emotional and pychosocial change from childhood to adulthood.
Because they are growing rapidly, becoming sexually mature, and undergoing major emotional, psychological and social changes.
The WHO recommends the use of paediatric clinical staging charts and criteria for starting antiretroviral treatment for adolescents younger than 15 years of age and adult clinical staging charts and starting criteria for adolescents who are 15 years of age or older. Paediatric doses of antiretroviral drugs are usually recommended for adolescents in early puberty (Tanner stages 1 to 3) and adult doses for adolescents in late puberty with full physical maturation (Tanner stage 4 and 5).
Boys usually have an earlier sexual debut (first experience) than girls. However, the prevalence of HIV infection is much higher in adolescent girls than boys, as young girls usually have older male partners. Girls, especially homeless or orphaned girls, may also be sexually abused or sell/swap sex for financial or other favours. The immature cervix is easily infected by HIV.
During adolescence girls are at higher risk of HIV infection than boys.
Every effort should be made to meet the special needs of adolescence. This is best done at a youth centre. This is a clinic where the facilities, staffing and care are designed to make it user-friendly to both HIV-positive and negative adolescents. The features of a youth centre are:
If there is no youth centre, general HIV clinics should at least be adolescent friendly. The staff usually consists of nurses, doctors, counsellors, social workers and psychologists who work together as a multidisciplinary team. It is hoped that more youth centres (adolescent-friendly centres) will be opened in future.
An adolescent-friendly approach with peer support is very important.
All adolescents must have sex education and be given the life skills to protect themselves and others from HIV infection. This should be taught in the home, schools, peer groups and health services. They need to become confident and have the knowledge to take responsibility for their lives.
Yes, but only when they have reached an age and stage of maturity when they can understand and handle this information. Revealing a child’s HIV status is a process over a number of years and not a once-off event. It can be compared to telling an adopted child the details of their parents and the adoption, or providing a child with sex education. They are provided with a little information at a time in a step-wise fashion. This is best done by simply and honestly answering their questions. It can be frightening and confusing to give too much detailed information too soon.
Parents often find this difficult and need the advice and support of health professionals. Failure of full disclosure by the time adolescence is reached can result in emotional difficulties, a lack of trust in the parents and health workers, and poor adherence. Every effort should be made to get the parents to agree to the disclosure.
It is important to give children information about their HIV status when they reach an appropriate age to accept the facts.
HIV-infected children often have a developmental age below their age in years. This should always be taken into consideration when counselling. Be led by the child’s questions and use language that the child can understand.
Usually parents are afraid but still prefer to provide this information themselves. They may need advice, encouragement and support from health workers. Some parents have difficulty with guilt and denial about their own infection and transferring HIV to their children.
An HIV-positive mother is told at the local clinic that it will be dangerous to immunise her six-week-old infant. She is asked to come back when the infant is three months old. No medications are given as the infant appears healthy.
Yes, they can be fully immunised, including BCG immunisation.
Prophylactic co-trimoxazole from six weeks. This can be stopped if HIV infection is excluded with a negative PCR test.
Because it reduces the risk of Pneumocystis pneumonia. It also reduces the risk of some serious bacterial infections.
Usually for the first year of life and thereafter until immune recovery has occurred. The risk of Pneumocystis pneumonia is less in older children.
Rash. This is usually mild but can be severe and even life threatening, especially in adults. Therefore parents should be warned to return to the clinic immediately if the child develops a rash.
A mother and her two HIV-infected children attend a primary-care clinic for a routine follow-up appointment. The clinic practises family-centred care. She is concerned as her four-year-old daughter has lost weight recently. A neighbour said that the child may have worms.
With family-centred care the whole family is taken into consideration when the child is seen. Many of the health problems in children are a direct result of family problems such as poverty, neglect and abuse. Therefore the family cannot be ignored.
By plotting the child’s weight on the Road-to-Health card. It is particularly important to chart this child’s weight as there is some concern that she has lost weight recently.
Yes. Therefore they should be regularly dewormed every six months. Usually mebendazole or albendazole is used.
An adolescent is seen by a general practitioner as she is embarrassed to attend the local clinic. The doctor diagnoses primary syphilis and is concerned that she is not practising safer sex. After counselling her, he performs a rapid test for HIV and this is positive.
The WHO defines adolescence as young people between the ages of 10 and 19 years. Adolescence is the time of physical, emotional and psychosocial change from childhood to adulthood. The first signs of puberty usually indicate that the child should be regarded as an adolescent.
Because the clinic does not have a ‘youth-centred’ approach.
Train their staff to be adolescent-friendly by being welcoming, non-judgemental and to respect and understand the concerns of young people. Adolescents prefer an informal atmosphere and appreciate peer support groups.
Almost certainly by sexual intercourse as she has another sexually transmitted infection. However, some perinatally HIV-infected children are now reaching adolescence.
Because they often are still emotionally immature and inexperienced. Therefore they are at risk of abuse and may sell sex to older men for financial or other favours.
By delaying sexual debut, limiting the number of sexual partners and always using a condom. In order to achieve this they need education about how to live a healthy lifestyle.
An HIV-infected woman asks a nursing friend how she should tell her young son that he also has HIV infection. He is starting to show the first signs of puberty.
Yes, but only when they have reached a stage of maturity when they are old enough to understand what this means and to emotionally handle the information. It is not helpful to provide too much information too soon. Older children have the right to know their status.
This should be a slow process starting when the child is young. As they grow older they can be given more information. Very young children need security and encouragement to take their medication. By the age of five most children can understand that they have a chronic illness and why they have to take regular medication. Older children can be given information about HIV and the implication this has in their lives. As this child is entering puberty he should be able to accept and understand the cause, clinical symptoms and prognosis of HIV infection.
Their parents or carers if possible. Parents often find this difficult and need the advice and support of health workers.
By answering their questions simply and honestly.
Yes. This is very important so that he can prevent spreading HIV to others.
At this age only family and close friends. Children may need help and support in disclosing their HIV status.