Module II: Diagnosing Paediatric HIV Key Questions: How and where do we identify HIV exposed and infected infants and children? What HIV tests should be done on which children and when? What are common symptoms of HIV exposed and infected children? What tool can I use to correctly diagnose and test children?

Without diagnosis and treatment, infants die Mortality Rates for untreated children with HIV At 1 year 30% At 2 year 50% At 5 year 66 – 75% At 10 years 85% Infants are most severely affected by HIV infection. Infants respond well to treatment if identified early enough. This slide is meant to emphasize that fact that HIV progresses faster in children. The facilitator must emphasize the fact that much as their disease progress is fast, they also respond well to treatment when identified early. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional 2

MOH-Paediatric HIV/AIDS training for Health professional Put into real numbers… If 10 positive children are born and none get care… This put the percentages in previous slide into reality. By one year not that 3 out of 10 children will have died and only 7 are remaining.( 1/3) By 2 years half of the children have died By 10 years 8 out 10 have died. Birth 1 year 2 years 10 years 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

by allowing us to diagnose children before they get sick. But early diagnosis and treatment decreases AIDS-related pediatric mortality by 75% CHER study in south Africa showed that Starting infants on ART as soon as possible after diagnosis leads to 75% reduction in mortality compared to those in whom treatment initiation is delayed until immunological decline and clinical symptoms develop. After this slide, the facilitator should then divide the team into 3 groups for group discussion as guide by allowing us to diagnose children before they get sick. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Where do we identify HIV infected and exposed children from? The facilitator should solicit responses from participants before moving to the next slide. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Exposed infants can & should be captured at many different points within a health facility Maternity (at birth) PNC Paediatric OPD Nutrition Unit ANC/PMTCT services Paediatric HIV-Care Lower level health facilities Adult HIV Services (HIV Care, VCT) Infants should be identified at all points within the facility and even in the community. Infants can as well be identified in adult wards. eg you may find an HIV positive man admitted on the ward and the wife is taking care of him but has young baby . That mother and baby should be tested for HIV. If mother is positive this child even if well, should have a PCR test, start on septrin and should be referred for care and follow up. Paed wards Community: OVC Support Services, Support Groups & PLHA Associations CBOs/NGOs/FBOs, Women groups 4/20/2017

Summary of the process for proactively identifying HIV-exposed infants infants 1. Check child health card of every infant for mother’s HIV Status If mother is HIV-positive, counsel and refer infant for PCR testing 2. Check mother’s ANC card if no indication from child card 3. If mother’s HIV status unknown, perform a rapid HIV test on her If mother is HIV-positive, refer her to immediate ART care and her infant for PCR testing 4. If unable to HIV test mother, perform a rapid HIV test on infant If infant’s rapid test is positive, he/she is HIV-exposed. Counsel & refer for PCR testing Facilitator should be familier with PMTCT codes. Most time participants know this These codes are indicated in the ANC and Child health card and can be used to identify which infant is Hiv exposed. TR- Test and HIV negative TRR- tested and HIV positive . TRRDm Tested, Positive and mother received drug TRRDmb Tested , Positive , both mother and baby received drug. 4/20/2017

Activity: Diagnosis and Testing for different age groups Groups 1 & 2: Infants to <18 months Groups 3 & 4: > 18 months Task: Each group will answer the following questions for your assigned age: Who should be tested? When should they be tested? Which tests should be done? 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Who needs to test? All children with an HIV+ MOM TRR They should be able to tell which babies are exposed from the process of proactively identifying exposed infants. Need to emphasize where they should look in the Child health care and ANC for the codes. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Who needs to test? All children with UNKNOWN status For all children with unknown Status, the mothers HIV status should be determined first then if she is positive , then the child should be tested for HIV. This means RTC should be active at all entry points in the facility. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Who needs to test? Any child, especially those who are sick with signs of possible HIV (even if previously tested negative) SICK 1. HIV doubles the energy needs of our bodies, causing weight loss. 2. A weakened immune system results in infections. Some infants are still likely to come with infections that are suggestive of HIV. Some infants have not go through PMTCT at all and they don’t access early testing and treatment and are likely to develop infections. There should be active identification of these infants in the Paediatric wards and OPD and should be tested. At this point you need to emphasize the importance of RTC in the paed ward and OPD, Nutrition unit. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Common signs and symptoms of HIV in exposed babies Dental Caries Molluscum Contagiosum Need to emphasize that these are signs of Late HIV infection. If early diagnosis is done and treatment started most infants will not reach this stage of illness. They will have normal growth. Much as we shall have some children still presenting with these, we need to put emphasis on early diagnosis and treatment so that we have children grow normally. Generalized lymph node enlargement (swelling) Photos from MOH, Uganda EID training program (2010) 3 yrs old 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional Ear infections Severe Wasting Stunted Growth 12

Common signs and symptoms of HIV in exposed babies Skin lesions (common in Kaposi’s Sarcoma) Skin Rash Oral Thrush Photos from MOH, Uganda EID training program (2010) Fungal Infections 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional Herpes Zoster 13

What’s in a drop of blood in someone with HIV? Antibodies (body’s reaction to the virus) In a child < 18m both mom and baby antibodies can be present Mom’s Antibodies Antibodies are our bodies’ reaction to the virus In children under 18 months of age, you have both maternal antibodies. This makes use of antibody tests unreliable for diagnosis of HIV in these children. This slide builds on knowledge for why DNA PCR test is recommended for children under 18 months while rapid tests can be used for infants 18 month and above. Baby’s Antibodies HIV virus 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Which test should you use? Choose based on child’s age The definitive diagnosis of HIV infection in children at any age requires diagnostic testing that confirms the presence of HIV. 6 weeks to <18 months 18 months and above DNA PCR using Dry Blood Spot (DBS) (Virologic) Serial Rapid Tests (Antibody) Because mom’s antibodies can stay in a child’s blood until 18 mos, we have to use a DNA PCR test in children < 18m to look for the virus itself 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Activity: Using the HIV Testing Algorithm to take appropriate actions Use the Testing Algorithm to answer the following questions: 1. Why and when would you perform a rapid test on an infant? You have a confirmed HIV+ mother who is still breastfeeding, and the exposed infant’s first PCR was negative, what should you do next and when? Is one positive PCR test enough to start a child on ART?

Diagnosis & Testing Practice Case #1 A 3.5 month old child comes to YCC for immunization. How do you go about determining the exposure status of the child? If the child is HIV exposed what test do you do? If the test is positive what would you do? d) If the test is negative what would you do? The participants should be able to go through the process of proactively identifying exposed infants as stated in the slide 11. b)The recommended test for this child is DNA PCR.DBS is used to take a sample. c) If Positive would refer the children to ART clinic, start septrin and ART. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

Diagnosis & Testing Practice Case #2 You have a 2 year old child who presents in OPD with oral thrush What test would you use to diagnose HIV in this child? b) If it is negative what would you do? c) If it is positive what would you do? Use HIV rapid test If Negative repeat a test after 3 month If positive start septrin, refer to ART clinic , stage and do CD4 count 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

MOH-Paediatric HIV/AIDS training for Health professional You should never let a mother leave the health center without trying to determine her infant’s HIV exposure status These are key messages to summarise the talk. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

We can make a difference! 1. PREVENT EARLY PMTCT Pro-active HTC 2. TEST EARLY This is a key message 3. TREAT EARLY ARVs 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional

MOH-Paediatric HIV/AIDS training for Health professional For those HIV infections that we cannot prevent, we CAN identify them early and keep them healthy. This is a key message. As you can note from the pictures, the children smiling and healthy though HIV infected. 4/20/2017 MOH-Paediatric HIV/AIDS training for Health professional