1. 1 Diagnosis of HIV Infection in Children HAIVN Harvard Medical School AIDS Initiatives in Vietnam

2. 2 Learning Objectives By the end of this session, participants should be able to: Explain why early diagnosis of HIV in young children is important Apply the algorithm of HIV diagnosis by age groups in diagnosing HIV in infants and children

3. 3 Overview In 2011, there were about 330 000 new HIV infection in children Mother-to-child transmission accounts for the majority of HIV- infection in children <15 years Diagnosis of HIV is challenging in infants in resource-limited countries

4. 4 Why is Early Diagnosis Crucial ?

5. 5 Early Diagnosis is Crucial (1) Early diagnosis of HIV helps to: identify HIV infected children before they become symptomatic allow healthcare providers to make appropriate care and treatment: Register at HIV OPC Assist on infant feeding Provide OI prophylaxis Prescribe ART

6. Early Diagnosis is Crucial (2) Newell ML et al. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: A pooled analysis. Lancet 2004; 364:1236-43. 18 months

7. 7 Early Diagnosis in Children < 18 Months Old

8. 8 Early HIV Diagnosis in Children <18 Months Old Diagnosis of HIV in this age group: ELISA cannot be used as maternal antibodies are still present, rendering antibody-based testing for HIV unreliable PCR can detect viral DNA/RNA directly and is the test of choice (which can be done at 4-6 weeks of age)

9. Time Frame for PCR WHO Technical Publication No. 51: Management of HIV infection in infants and children: A clinical manual 2006. Presence of HIV antibodies (from mother) in HIV-exposed but un-infected children Early Diagnosis by PCR 6 weeks

10. 10 Early Diagnosis Using Dried Blood Spot (DBS) DBS is prepared by putting drops of blood on a piece of paper and allowing them to dry Can be stored and shipped to testing facilities at room air, over 3-7 days PCR using DBS is as effective as PCR using liquid blood samples

11. 11 HIV Diagnosis in Infants < 9 Months Old If positive: Initiate ARV treatment Do 2 nd PCR for confirmation as soon as possible Continue if breastfeeding If negative: Wait until infant is 18 months old to perform ELISA for confirmation Advise replacement feeding if possible PCR with DBS at 4-6 weeks of age

12. 12 HIV Diagnosis in Infants between 9-18 Months Old If positive: Follow PCR algorithm If negative: Infant is likely not HIV-infected Perform HIV antibody test

13. 13 HIV Diagnosis in Infants < 18 Months Old and Suspected to Have HIV If positive  confirm diagnosis with PCR (if PCR not available, apply clinical criteria) If negative  child does not have HIV HIV-antibody test

14. 14 HIV diagnosis in infants < 18 months old All children who have either: first PCR negative or second PCR negative will be confirmed the HIV status by ELISA tests at the age of 18 months

15. 15 Case Studies

16. 16 Clinical Diagnosis for Severe HIV/AIDS in Children < 18 Months (1) Apply clinical diagnostic criteria when virologic testing (PCR) is not available: HIV antibody positive 1 clinical stage IV diagnosis At least 2 out of 3 1. Oral candidiasis 2. Severe bacterial pneumonia 3. Severe sepsis or HIV antibody positive + +

17. 17 Clinical Diagnosis of Severe HIV/AIDS in Children < 18 Months (2) Other factors assisting clinical diagnosis of severe HIV/AIDS disease: Child born to a mother who: has just died of HIV-related disease, or has advanced HIV/AIDS disease Child’s CD4 percentage < 20% In these cases, definitive diagnosis with virological testing should be done as soon as possible.

18. 18 HIV Diagnosis in Children > 18 Months Definitive diagnosis of HIV infection in children >18 months of age is based on HIV antibody test HIV infection is confirmed when the serum is positive with 3 tests using 3 different bioproducts

19. 19 Key Points Early diagnosis allows healthcare providers to make appropriate care and treatment In exposed children <18 months, HIV infection should be confirmed as early as possible using PCR Clinical diagnosis of severe HIV/AIDS in infants should be considered if HIV is suspected

20. 20 Thank you! Questions?