Pediatric HIV

Aka: Pediatric HIV, Pediatric AIDS, HIV Related Pediatric Concerns, Newborn HIV Prophylaxis, Neonatal HIV Prevention

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II. Epidemiology

  1. Definitions
    1. Pediatric refers to under age 13
  2. Pediatric HIV Prevalence
    1. World: 2.5 Million
    2. United States: 10,834 (in 2009)
      1. Universal screening and management protocols for HIV in Pregnancy have kept these numbers low in United States
      2. Pediatric HIV due to perinatal transmission is now less than 200/year in United States
  3. Pediatric AIDS Prevalence
    1. Worldwide: 1 million
    2. United States: 6611
  4. Mortality
    1. AIDS is the leading cause of death in ages 1-4

III. Pathophysiology: Common modes of transmission (acquisition)

  1. Hemophilia
  2. Transfusion (risk of 1 in 425,000 by HIV ELISA test)
  3. Foreign adoptee
  4. Perinatal HIV Transmission
    1. Accounts for 90% of cases under age 13 years
  5. Adolescents with high risk behaviors
    1. Accounts for 50% of new HIV cases in the United States under age 18 years

IV. Clinical Manifestations

  1. Generalized Lymphadenopathy
    1. Lymph Nodes may be size of Lymphoma nodes
  2. Hepatosplenomegaly
  3. Recurrent Candidiasis (especially Thrush over age 2 years old)
  4. Chronic Diarrhea or Recurrent Diarrhea
  5. Developmental Delay
  6. Encephalopathy
  7. Failure to Thrive
  8. Lymphocytic Interstitial Pneumonitis (LIP)
  9. Pneumocystis carinii Pneumonia
    1. May be first indicator of perinatal HIV Infection
    2. Peak Incidence at age 3 to 6 months
    3. May occur regardless of CD4 Count

V. Labs: Diagnosis with HIV detection

  1. Child under age 18 months
    1. Protocol
      1. Birth
        1. Obtain HIV Nucleic Acid testing (HIV PCR RNA or DNA) at 4 days of age
        2. Obtain 2 separate blood samples (for confirmation testing if positive)
        3. Do NOT use cord blood sample (risk of contamination with maternal blood)
      2. Age 1 months
        1. Obtain HIV Nucleic Acid testing (HIV PCR RNA or DNA) at 1 month of age
        2. Two negative tests (birth and 1 month) presumptively exclude HIV
      3. Age 2 months
        1. Obtain HIV Nucleic Acid testing (HIV PCR RNA or DNA) at 2 months of age
        2. One negative test (2 month) presumptively excludes HIV
      4. Age 4 months
        1. Obtain HIV Nucleic Acid testing (HIV PCR RNA or DNA) at 4 months of age
        2. Two negative tests (1 month and 4 months) definitively excludes HIV
      5. Age 6 months
        1. Obtain HIV Nucleic Acid testing (HIV PCR RNA or DNA) or HIV Antibody at 6 months of age
        2. One negative test (2 month) presumptively excludes HIV
        3. Two negative HIV Antibody tests from separate specimens at 6 months definitively excludes HIV
      6. Age 12 months
        1. Consider HIV Antibody testing at 12-18 months to confirm HIV seronegative status
    2. HIV PCR - RNA or DNA, viral load (>95% sensitive by 3 months)
      1. Cost: $200
      2. Indicated for HIV diagnosis (primary surveillance test)
      3. Similar accuracy as HIV virus culture
    3. Other tests
      1. HIV virus culture
        1. Efficacy: >95% sensitive by 3 months
        2. Cost: $200
        3. Blood Culture must be sent same day
      2. HIV Antigen P24 assay
        1. High Specificity, low sensitivity
        2. Cost: $35
        3. Does not rule-out HIV if negative
    4. AVOID HIV ELISA and HIV Western Blot (unreliable <18 months of age)
      1. IgG to HIV acquired transplacentally
      2. Every infant born to an HIV infected mother will test positive for HIV Antibody
      3. HIV Antibody disappears in 98% infants by 18 months
  2. Child over age 18 months
    1. Screening: HIV ELISA
    2. Confirmation: HIV Western Blot
  3. Sero-reverter of child born to HIV positive mother
    1. Assumed child is uninfected when:
      1. ELISA HIV negative >18 months of age
      2. HIV PCR or HIV Culture negative twice
        1. At least one sample must be after 6 months

VI. Labs: Other initial findings

  1. Hypergammaglobulinemia (IgG, IgM, IgA)
  2. T-Cell Levels: Low CD4 Count and Low CD8 Count
    1. T-Cells even at normal levels, function poorly in infants
    2. Pneumocystis Pneumonia can occur despite normal T-Cell levels in infants
    3. CD4 Count of 500 in an infant under age 1 year old is equivalent to an adult with a CD4 Count of 200
  3. Complete Blood Count (at delivery and 4 weeks later)
    1. Lymphocytes <10% is a concerning finding
    2. Low Platelets
    3. Anemia
    4. Neutropenia
  4. Liver Function Tests
    1. Elevated transaminases

VII. Labs: Monitoring

  1. See HIV detection above for HIV PCR protocol
  2. PPD Skin Testing annually after 12 months
  3. Complete Blood Count monthly from birth to 4 months
  4. CD4 Count at 1 and 3 months
    1. See T-Cell Levels above for precautions about interpretation in infants and children

VIII. Complications: Changes specific to Pediatric HIV compared to Adult HIV

  1. Rapid progression (In Utero transmission)
    1. See HIV in Pregnancy
  2. Increased Incidence of Encephalopathy
  3. Failure to Thrive
  4. Recurrent Bacterial Infection
  5. Lymphocytic Interstitial Pneumonitis (LIP)
  6. Decreased Incidence of malignancies

IX. Management: Disposition

  1. Consider comorbid infections
    1. Syphilis
    2. Hepatitis B
    3. Hepatitis C
    4. Tuberculosis
    5. Herpes Simplex Virus
    6. Zika Virus
    7. Toxoplasmosis
    8. Cytomegalovirus
  2. Continue Antiretroviral therapy uninterrupted
    1. Family should leave hospital with adequate supply
  3. Follow-up
    1. First primary care at 2 weeks
    2. Review Medication Compliance and adverse effects at each visit
    3. Consult infectious disease if HIV positive
    4. Monitor blood count (see above), growth and development
    5. Monitor growth and development
    6. Monitor for Acute HIV Infection symptoms (e.g. fever, rash, Pneumonia)
    7. Administer all recommended primary care Vaccines except live virus (Zoster, VZV, Rotavirus, Polio, MMR)
  4. Anticipatory Guidance
    1. HIV Positive women should not Breast feed
    2. Avoid solid foods before 4-6 months
    3. Avoid food premastication due to risk of HIV Transmission (parent chews food first, then feeds infant)

X. Management: Newborn HIV Prophylaxis in Infants born to HIV Positive Mothers

  1. Intrapartum
    1. See HIV in Pregnancy
  2. Newborn Low Risk Protocol
    1. Indications
      1. Antiretroviral therapy continued throughout pregnancy AND
      2. Sustained HIV RNA viral load <50 copies/ml tested near the time of delivery
    2. Antiretroviral Treatment
      1. Zidovudine (Retrovir) 2 mg/kg orally every 6 hours for four weeks, starting within 8 hours of delivery
    3. Monitoring
      1. Obtain nucleic acid at 2-3 weeks of age, 1-2 months of age and 4-6 months of age
  3. Newborn High Risk Protocol
    1. Indications
      1. Patient's not meeting low risk criteria OR
      2. No antepartum drugs or intrapartum Retroviral drugs OR
      3. Inadequate HIV Viral Load suppression (esp. if Vaginal Delivery)
      4. Acute HIV or Primary HIV Infection
    2. Antiretroviral Treatment
      1. Administer one of two regimens from birth to 6 months of age, starting within 8 hours of delivery
      2. Combined Zidovudine (ZDV), Lamivudine (Epivir) and Nevirapine (Viramune at treatment dosing) OR
      3. Combined Zidovudine (ZDV), Lamivudine (Epivir) and Raltegravir (Isentress)
    3. Monitoring
      1. Obtain nucleic acid at 2-3 weeks of age, 1-2 months of age, 2-3 months and 4-6 months of age
  4. Newborn Monitoring for Anemia
    1. Follow Complete Blood Count as above
    2. Mild Anemia peak at 6 weeks, resolves by 12 weeks
    3. No treatment usually necessary

XI. Management: Prophylaxis in HIV positive children

  1. Immunoglobulin IV
  2. Mycobacterium Avium Complex (MAC)
    1. Clarithromycin
    2. Azithromycin
  3. Pneumocystis carinii prophylaxis
    1. Agents
      1. Preferred: Trimethoprim-Sulfamethoxazole (Septra)
      2. Start at 6 weeks of age if HIV cannot be presumptively excluded
      3. Dose: 5 mg/kg/day of TMP component divided twice daily
        1. Lower dose than usual 8 mg/kg/day
        2. Frequency: Twice daily for 3 days per week
      4. Alternative agents
        1. Dapsone
        2. Atovaquone
    2. CD4 Count to Start Prophylaxis dependent on age
      1. Age under 12 months: All infants on prophylaxis
        1. Start prophylaxis at 6 weeks of age
        2. May stop if HIV PCR still negative at 4 months
        3. Continue until 12 months if HIV positive
        4. Base prophylaxis on CD4 Count after 12 months
      2. Age 1-11 months: CD4 Count < 1500 cells
      3. Age 12-23 months: CD4 Count < 750 cells
      4. Age 2-5 years: CD4 Count < 500 cells
      5. Age >6 years: CD4 Count < 200 cells
  4. Tuberculosis exposure
    1. Testing
      1. PPD skin test (positive if 5 mm or greater)
      2. Chest XRay
    2. Protocol after Tuberculosis exposure
      1. Prophylaxis even if PPD negative
      2. Isoniazid prophylaxis for 3 months
      3. Repeat PPD at 3 months
        1. May stop Isoniazid if PPD negative
        2. Continue Isoniazid if PPD positive
  5. Immunizations
    1. See Immunization in HIV
    2. Influenza Vaccine at 6 months and then yearly
    3. Routine Immunizations
      1. Give IPV instead of OPV
      2. Varicella Vaccine (if CDC Immune Category I)
      3. MMR Vaccine (if CDC Immune Category I or II)

XII. Precautions: Acute Illness

  1. Aggressively manage adolescents with HIV (frequently non-compliant with medication regimens)
  2. Exercise low threshold for admission for children with HIV and a low age-adjusted CD4 Count
  3. Headache and fever should be evaluated with head imaging and Lumbar Puncture
    1. See Headache in HIV

XIII. Prevention

  1. Minimize exposure and evaluate infectious contacts
    1. Tuberculosis
    2. Varicella Zoster Virus (VZV)
  2. Prevent opportunistic infection
    1. Avoid undercooked foods (Salmonellosis)
    2. Avoid cat litter box exposure (Toxoplasmosis)
    3. Consider using only bottled or purified water
      1. Giardiasis
      2. Cryptosporidiosis

XIV. Prognosis: Distinct patterns of disease progression

  1. Rapid (30%)
    1. Associated with in utero transmission
    2. Symptom onset in first 6 months of life
  2. Slower (70%)
    1. Symptom onset in first 3 years of life
  3. Adult equivalent (<5%)
    1. Symptom onset at 10 years of life

XV. References

  1. Church and Claudius in Majoewsky (2013) EM:Rap 13(8): 7-8
  2. (1998) MMWR Morb Mortal Wkly Rep 47(RR-4):1-43 [PubMed]
  3. Krist (2002) Am Fam Physician 65(10):2049-56 [PubMed]
  4. Vijayan (2021) Am Fam Physician 104(1): 58-62 [PubMed]

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