Paeds · infectious-diseases
HIV exposure and infection in children
Also known as Paediatric HIV · Perinatally-acquired HIV · Vertically-transmitted HIV in children · HIV-exposed infant (HEU) · Mother-to-child HIV transmission
Fellowship topic on HIV exposure and infection in children: mother-to-child transmission in utero, intrapartum and through breastfeeding and how combination ART compresses each; the PMTCT cascade from maternal ART (Option B+) through infant nevirapine prophylaxis to early infant PCR diagnosis; the distinction between HIV exposure and HIV infection (maternal IgG versus infant viraemia); rapid infant progression and the survival benefit of immediate ART; HIV DNA/RNA PCR as the diagnostic test under 18 months; cotrimoxazole prophylaxis and the prevention of Pneumocystis pneumonia; WHO clinical staging and CD4-based immunological staging; the HIV-exposed-uninfected infant; opportunistic infection, failure to thrive and HIV encephalopathy; feeding decisions, family testing and adolescent transition; and WHO, CDC, PENTA and ANZ/UK/US/Canada guidance.
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Red flags
- A hypoxic infant aged 3–6 months born to an HIV-positive mother — suspect Pneumocystis pneumonia and treat empirically with high-dose co-trimoxazole while confirming; delay is lethal
- Failure to thrive with recurrent or severe infection in an exposed or untested infant — diagnose with PCR, not antibody, and do not assume maternal antibody explains a positive antibody test
- Developmental delay or regression with loss of milestones — consider HIV encephalopathy in the context of untreated infection
- A newly diagnosed HIV-positive breastfeeding mother postpartum — start maternal ART and infant nevirapine prophylaxis immediately and arrange early infant PCR
- An adolescent with vertically-acquired HIV disengaging from care — loss of viral suppression is the route back to AIDS; address adherence, disclosure and transition urgently
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Infectious Diseases: perinatal HIV — transmission, diagnosis and the exposed infant
- Immunisation and prophylaxis: cotrimoxazole and the PMTCT cascade
- Renewed curriculum — Infectious diseases: paediatric HIV diagnosis, early ART, opportunistic infection and the treat-all strategy
- Community and population child health: PMTCT/Option B+, breastfeeding decisions and equity in the cascade
- General Paediatrics: the HIV-exposed infant — PCR diagnosis, prophylaxis and the failing child
- Neonatal and maternal interface: maternal ART, viral load and infant prophylaxis at delivery
- Long Case / Structured discussion: the failing infant or child with HIV — diagnosis, ART, opportunistic infection and prognosis
- Communication station: explaining PCR diagnosis, feeding choice and lifelong ART to a family
- Level 2 / 3 — Infection: paediatric HIV as a vertically-acquired infection; PCR diagnosis, ART and opportunistic-infection prevention
- Public health and immunisation: the PMTCT cascade, cotrimoxazole prophylaxis and the exposed-infant pathway
- Foundation of Practice (FOP): perinatal HIV transmission, rapid infant progression and the exposed infant
- Applied Knowledge in Practice (AKP): PCR diagnosis, ART, cotrimoxazole, PCP and the treat-all strategy
- History-taking and management: the failing infant or child with suspected HIV
- Communication: explaining diagnosis, feeding and treatment to a family
- General Pediatrics Content Outline — paediatric HIV: vertical transmission, PCR diagnosis, ART and opportunistic infection
- Infectious Diseases: HIV mother-to-child transmission, Pneumocystis prophylaxis and the treat-all approach
- Bright Futures / adolescent: transition of the HIV-infected adolescent to adult care
- Patient Care: diagnosis and stepwise management of paediatric HIV and the exposed infant
- Systems-Based Practice and Population Health: PMTCT, Option B+, breastfeeding counselling and equity in the cascade
- Medical Knowledge: HIV pathophysiology, rapid infant progression and antiretroviral strategy
- Medical Expert: paediatric HIV diagnosis, ART and opportunistic-infection management
- Health Advocate and Collaborator: PMTCT, maternal–child HIV coordination and equitable access
- Communicator: explaining PCR diagnosis, feeding and lifelong treatment to a family
Exposure is not infection
HIV-exposed, uninfected (HEU)
HIV-infected (confirmed)
Maternal IgG crosses the placenta and lingers in the infant's blood for up to 18 months. A positive antibody test in a baby tells you about the mother, not the child. To diagnose infection you must detect the virus itself — by HIV DNA or RNA PCR — and confirm a positive result with a second sample. The rule: PCR, not antibody, under eighteen months. [7]
Overview & Definition
Picture a six-week-old baby brought to clinic for the routine immunisation visit. The mother is HIV-positive and on antiretroviral therapy, her viral load was suppressed at delivery, and the baby received nevirapine for six weeks. A single antibody test on this baby would be positive — yet the baby may well be uninfected. The skill of the paediatrician is to hold exposure and infection apart, to test for the virus rather than the antibody, and to run the cascade that either confirms infection and starts treatment, or proves the baby is uninfected and closes the chapter. [7] [1]
Human immunodeficiency virus (HIV) in the child is almost always acquired vertically — from an HIV-positive mother during pregnancy, at delivery, or through breastfeeding. A smaller share is acquired through blood products, sexual contact, or, in adolescents, horizontal routes. The defining clinical fact is that exposure and infection are not the same: an HIV-exposed infant is born to a positive mother but may be uninfected, and only nucleic-acid testing can tell the two apart in the first 18 months of life. [4] [7]
The clinician's work runs on three layers. The acute layer recognises and treats the failing child — the infant with Pneumocystis pneumonia, the wasted toddler with chronic diarrhoea, the adolescent with advanced disease. The definitive layer diagnoses infection by PCR, starts ART immediately, and delivers cotrimoxazole, nutrition and opportunistic-infection care. The preventive layer runs the PMTCT cascade — maternal lifelong ART, an undetectable viral load, infant prophylaxis, safe feeding and structured follow-up — because the child who never acquires infection is child programme has protected. [1] [10]
References10ShowHide
- [1]Violari A; Cotton MF; Gibb DM; Babiker AG; et al Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med, 2008.PMID 19020325
- [2]Chasela CS; Hudleston MJ; Jamieson DJ; Kayira D; et al Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med, 2010.PMID 20554982
- [3]Jamieson DJ; Chasela CS; Hudleston MG; King CC; et al Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial. Lancet, 2012.PMID 22541418
- [4]Newell ML; Coovadia H; Cortina-Borja M; Rollins N; et al Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet, 2004.PMID 15464184
- [5]Foster C; Pace M; Kaye S; Hopkins E; et al Paediatric European Network for Treatment of AIDS Treatment Guideline 2016 update: antiretroviral therapy recommended for all children living with HIV. HIV Med, 2017.PMID 27385585
- [6]Slogrove AL; Mahy M; Armstrong A; Davies MA Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic. J Int AIDS Soc, 2017.PMID 28530036
- [7]Havens PL; Mofenson LM; American Academy of Pediatrics Committee on Pediatric AIDS Evaluation and management of the infant exposed to HIV-1 in the United States. Pediatrics, 2009.PMID 19117880
- [8]Mofenson LM; Brady MT; Danner SP; Dominguez KL; et al Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children. MMWR Recomm Rep, 2009.PMID 19730409
- [9]Kacanek D; Huo Y; Laskey B; Mellins CA; et al Pediatric Neurodevelopmental Functioning After In Utero Exposure to Triple-NRTI vs. Dual-NRTI + PI ART in a Randomized Trial, Botswana. J Acquir Immune Defic Syndr, 2018.PMID 30015793
- [10]Barlow-Mosha L; Angelidou K; Lindsey JC; Archary M; et al Universal antiretroviral therapy for HIV-infected children: a review of the benefits and risks to consider during implementation. J Int AIDS Soc, 2017.PMID 28691434