INTEGRATED MANAGEMENT IMCI
OF CHILDHOOD ILLNESS
DISTANCE LEARNING COURSE
HIV/AIDS
Module 8
15 booklets
Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation:
introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance.
7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)
© World Health Organization 2014
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n CONTENTS
Acknowledgements 4
8.1 Module overview 5
8.2 Basic information about HIV 9
8.3 HIV testing 16
8.4 Assess & classify a sick child 24 8.5 Assess & classify a sick young infant 31 8.6 Prophylaxis and other preventative measures 36 8.7 Counsel HIV-infected mothers about infant feeding 47
8.8 Antiretroviral treatment 63
8.9 Providing follow-up care 91
8.10 Review questions 110
8.11 Answer key 111
ANNEXES
Annex 1 Clinical staging 121
Annex 2 Treatment dosing tables 123
Acknowledgements
The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/
AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development.
Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO.
A particular debt of gratitude is owed to the principal developer, Ms Megan Towle.
Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania
WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules.
We acknowledge the help from Ms Sue Hobbs in the design of the materials.
Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.
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8.1 MODULE OVERVIEW
This module will teach you how IMCI can assist in providing critical HIV/AIDS care, treatment, support, and prevention.
Worldwide, 3.4 million children were living with HIV in 2011
First, this module will explain basic information about HIV and how children are infected. This information will help you better manage children with suspected or confirmed infection. Next, you will learn how to assess and classify HIV in young infants and children. You will learn how to provide follow-up care for exposed and infected children. The module will also explain how to counsel HIV-positive mothers about safe feeding, and methods for further preventing illness in exposed and infected children. Lastly, you will learn how to provide antiretroviral treatment and provide follow-up.
MODULE OBJECTIVES
After you study this module, you will know how to:
✔ Explain in basic terms how HIV affects the immune system
✔ Explain how children are infected with HIV
✔ Assess and classify a child for HIV
✔ Assess and classify a young infant for HIV
✔ Provide follow-up care to HIV exposed and infected children that are not on ART
✔ Counsel an HIV-infected mother about safe infant feeding, and preventing common illnesses in infants and young children exposed to, or infected with, HIV through cotrimoxazole prophylaxis, ARV prophylaxis, immunization, and Vitamin A supplementation
✔ Explain and provide the recommended ARV regimens for children
✔ Explain the criteria for initiating ART in children at first-level facilities
✔ Describe the WHO paediatric clinical staging process
✔ Identify the possible side effects of ARV drugs and explain the management of possible side effects
✔ Counsel the caregiver on giving ART and adherence
✔ Explain the principles of good follow-up care
✔ Provide chronic care for children with confirmed HIV infection and on ART
MODULE ORGANIZATION
This module is divided into multiple sections:
1. BASIC INFORMATION ABOUT HIV 2. HIV TESTING
3. ASSESSING & CLASSIFYING A CHILD FOR HIV
4. ASSESSING & CLASSIFYING A YOUNG INFANT FOR HIV 5. PROPHYLAXIS AND PREVENTIVE MEASURES
6. COUNSELLING THE HIV-POSITIVE MOTHER ABOUT INFANT FEEDING 7. ANTIRETROVIRAL THERAPY (ART)
8. PROVIDING FOLLOW-UP CARE
WHY IS THE IMCI STRATEGY USED WITH HIV?
Children with suspected or confirmed HIV infection have special needs. Therefore they need to be cared for differently from children who are not infected.
As you have learned, the IMCI strategy is designed to help health workers identify common health problems in children. It also helps identify underlying issues, like malnutrition and HIV.
WHERE DOES HIV FIT IN THE IMCI PROCESS?
You have learned that for every sick child or young infant, you check for signs of serious illness, assess and classify main symptoms, and check for malnutrition and feeding problems. Next, you will ASSESS and CLASSIFY for HIV using the same process.
CHECK for general danger signs or signs of serious illness ASSESS & CLASSIFY main symptoms
CHECK for malnutrition of feeding problems CHECK for HIV infection
CHECK immunizations and for other problems
7 WHAT IMCI TOOLS WILL YOU USE?
For this module, you will continue to use work aids provided earlier in the course:
1. IMCI Chart Booklet for HIV settings
2. IMCI recording forms for sick young infant and sick child You will also have additional work aids that are specific to HIV/AIDS care:
3. ART initiation form for the sick child (2 months up to 5 years) 4. ART follow-up form for the sick child (2 months up to 5 years)
Open your chart booklets now to review each of these tools. Identify the recording forms you will use for each set of charts.
BEFORE YOU BEGIN
What do you know now about managing HIV care?
Before you begin studying this module, quickly practice your knowledge with these multiple-choice questions.
Circle the best answer for each question.
1. A child is under 16 months old. What HIV test should be used for this child, and why?
a. Serological tests, because it can detect if virus antibodies are present b. Virological (PCR) tests, because it can actually detect the virus
c. Serological tests now, but after the child is 18 months, confirm with a PCR 2. What follow-up treatments are critical for HIV-exposed and infected infants
and children?
a. Cotrimoxazole prophylaxis b. Paracetamol
c. Amoxicillin
3. What is the overall risk of a mother transmitting HIV to her child during pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used during prevention of mother-to-child transmission?
a. 70%
b. 10%
c. 35%
4. A 2-month breastfeeding baby has a positive virological (PCR) test. Is the child HIV infected?
a. Yes, HIV-infected b. No, HIV negative
c. Possibly, he is HIV exposed
5. When is an HIV-positive child or infant eligible for ART?
a. If a child has stage 2 HIV infection
b. Any child under five with confirmed HIV infection
c. Children over 5 years old with a count less than 350 cells per mm3
6. If a mother is HIV-positive, but the child is not confirmed with HIV infection, what is the recommended feeding practice?
a. Exclusive breastfeeding as long as the child wants
b. Breastfeeding and also formula, in order to provide additional nutrition c. Exclusive breastfeeding until 12 months
After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!
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8.2 BASIC INFORMATION ABOUT HIV
What are the learning objectives for this section?
After you study this section, you will know how to:
• Explain in basic terms how HIV affects the immune system
• Explain how HIV is transmitted to infants and children
WHAT IS THE IMMUNE SYSTEM?
Every healthy person has a strong system to defend the body against diseases. This defence system is called the immune system.
White blood cells are an important part of this defence system. They protect the body against all kinds of diseases. They can be thought of as the “soldiers” of the body.
HOW DO WHITE BLOOD CELLS ACT AS “SOLDIERS”?
Lymphocytes are one type of white blood cell in the body.
Some of these lymphocytes have a marker on their surface called CD4. Therefore they are called CD4 lymphocytes. These CD4 lymphocytes are responsible for warning your immune system that there are germs trying to invade the body.
HIV (Human Immunodeficiency Virus) is a virus that infects and takes over cells of the immune system. Although HIV infects a variety of cells, its main target is the CD4 lymphocyte.
HOW DO VIRUSES INFECT THESE CELLS?
The human body is made of millions of different cells. Each body cell is able to make new cell parts, in order to stay alive and to reproduce.
Viruses take advantage of this ability. They hide their own material in the centre of the cell, called the nucleus. When the cell tries to make its own new parts, it also makes new copies of the virus. When the HIV virus infects CD4 lymphocytes, HIV uses the CD4 cell to make new copies of the HIV virus. These copies go on to infect other cells.
WHAT DOES HIV DO TO CD4 LYMPHOCYTES?
CD4 cells infected with HIV are not able to work very well. They die early. When the immune system loses these CD4 cells, the immune system becomes weaker.
This makes children (and adults) much more likely to develop illness from the types of germs that would not normally cause them to be ill, or to be more sick with common germs.
These infections are called opportunistic infections. They take the opportunity of the body’s defence system being weak to flourish.
CD4 lymphocytes warn your immune system that there are germs trying to invade the body.
HIV infects cells of the immune system. Its main target is the CD4 lymphocyte.
Figure 1 summarizes what happens to HIV after it enters a human cell.
Figure 1. HIV entering the cell and making new copies
HIV attacks many CD4 cells. The infected CD4 cell will first produce many new copies of the virus, and then die.
The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and then die.
This goes on and on – more CD4 cells are destroyed, and more copies of HIV are made.
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HOW IS HIV MONITORED ONCE IT INFECTS THE BODY?
When a person gets infected with the HIV, the virus will start to attack his/her immune system. Since HIV mostly attacks CD4 cells, there is a measurement of the number of CD4 cells in an HIV- infected person’s blood. This is a good way of checking how well their defence system is still working. This is called a CD4 count.
HOW DOES HIV AFFECT ADULTS?
During the first years following infection, an adult’s immune system can still function quite well, even though the HIV virus is slowly damaging the immune system. The infected adult will have no symptoms, or only minor symptoms such as swollen lymph nodes or mild skin diseases. At this stage, most adults do not even know that are infected with HIV.
Usually after several years, the adult’s immune system gets more and more damaged and weaker. The person becomes vulnerable to germs and diseases that they normally fight off. These infections are called ‘opportunistic infections’ because they take advantage of the weak immune system to cause disease.
In adults it usually takes around 7–10 years after the initial infection with HIV before the person becomes ill and develops serious sickness from HIV. HIV is considered to have progressed to AIDS when these sicknesses occur and a CD4 count reaches below a certain number.
HOW DOES HIV AFFECT CHILDREN DIFFERENTLY THAN ADULTS?
HIV infection progresses much more rapidly in children as compared to adults. The course of HIV infection is different in children than in adults because children’s immune systems are not yet well developed.
HIV seems to damage the immune system more easily in children. This is especially true if the child is infected with HIV while in the mother’s womb, or at the time of delivery.
Children are also more susceptible to common infections or unusual opportunistic infections. In the same way as adults, when the child’s immune system gets damaged it becomes weak. Children can get sick from germs that do not usually cause serious disease. For example, a child may normally have candida bacteria living in the mouth. However, when the immune system
is damaged, the candida causes mouth ulcers or soreness. This is called oral thrush.
As the damage to the immune system gets worse, children become highly vulnerable to life-threatening illnesses such as PCP pneumonia, unusual cancers (lymphoma), recurrent bacterial infections, and HIV brain damage (encephalopathy). These are considered AIDS-defining diseases because they are often seen once a child’s immune system is not performing well due to HIV infection.
As the HIV disease progresses, a child’s CD4 percent or total count gets less. Figure 2 illustrates how HIV attacks our health.
CD4 counts tell you how healthy a person’s immune system is.
HIV can usually weaken or destroy the immune system in children much more quickly.
Children progress from HIV to AIDS more rapidly.
Figure 2. How HIV attacks the body
1. The CD4 cell is a kind of white blood cell. The CD4
is the friend of our body. 2. Problems like cough try to attack our body, but the CD4 fights them to defend the body, his friend.
3. Problems like diarrhoea try to attack our body, but
CD4 fights them to defend the body. 4. Now, HIV enters and starts to attack the CD4.
5. The CD4 notices he cannot defend himself against
HIV! 6. Soon, CD4 loses his force against HIV.
7. CD4 loses the fight. The body remains without
defence. 8. Now the body is alone without defence. All
kinds of problems, like cough & diarrhoea, take advantage and start to attack the body.
9. In the end, the body is so weak that all the diseases can attack without difficulty.
body CD4
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HOW ARE CHILDREN INFECTED WITH HIV?
Mother-to-child transmission of HIV (MTCT) is the main way that young children are infected with HIV. This is also called vertical transmission.
Other ways in which children can get HIV are sexual abuse, unsafe injections, or blood transfusion with blood products that are infected with HIV.
HOW DOES MOTHER-TO-CHILD TRANSMISSION OF HIV OCCUR?
Mother-to-child transmission (MTCT) is when an HIV infected woman passes the virus to her baby. This can happen without the mother’s knowledge is she does not know her status. HIV can be transmitted from mother to child during several methods, and times:
1. Pregnancy (in utero)
2. Labour and delivery (peri or intrapartum) 3. Breastfeeding (postpartum)
Not all HIV infected women will automatically transmit the virus to their child.
WHAT IS THE RISK OF MOTHER-TO-CHILD TRANSMISSION?
Look at the diagram below. This will be an example. Consider 20 babies born to 20 HIV-infected women. If nothing is done to prevent HIV transmission in these 20 babies, then approximately 7 of the 20 women will transmit HIV to their infants during pregnancy, labour, delivery, or breastfeeding. This means that the overall risk of MTCT is about 35%.
This is visualized in the picture below, where 7 of 20 of babies are shaded. Of these 7 babies, it is estimated that about 4 of them (or 20% of the total infection risk) would be infected during pregnancy, labour, or delivery. The remaining 3 babies (or about 15% of the total infection risk) would be infected during breastfeeding. This risk is decreased if the mother or child receives ART prophylaxis.
PREGNANCY
& DELIVERY 4 out of 20
BREASTFEEDING
3 out of 20 NOT INFECTED 13 out of 20
If 20 women deliver babies without any intervenKon to reduce mother-‐to-‐child HIV transmission:
How many on average will be infected? 7 out of 20
4 (20%)
infected during pregnancy,
labout or delivery
3 (15%)
infected during breast- feeding
Why does transmission risk change during pregnancy, delivery, and breastfeeding?
The risk of transmission during pregnancy is low, as the placenta protects the developing baby. During labour and delivery the risk is increased through sucking, absorbing, or aspirating blood or cervical fluid.
Mixed feeding, compared to exclusive feeding, may increase the risk of HIV transmission. Studies have shown that exclusive breastfeeding carries a smaller risk of HIV transmission when compared
with mixed feeding. This is due to potential damage to the lining of the infant’s gut by food particles or the introduction of an allergen or bacteria that causes inflammation. This can lead to easier access of the HIV virus from the mother’s breast milk into the infant’s blood.
Exclusive breastfeeding reduces the risk of HIV transmission.
IMPORTANT NOTE ABOUT MOTHER-TO-CHILD TRANSMISSION
The term mother-to-child transmission is used in this document because the source of the child’s HIV infection is the mother. Use of the term mother-to-child transmission does not imply blame, whether or not a woman is aware of her own infection status.
A woman can acquire HIV through unprotected sex with an infected partner, or by receiving contaminated blood through non-sterile instruments or medical procedures.
WHAT DOES IT MEAN TO BE ‘HIV EXPOSED’?
For the purposes of this course, HIV-exposed infants are born to women who are known to be HIV-infected. HIV-exposed infants or children cannot be considered HIV-positive or HIV-negative until their status is confirmed with an appropriate HIV test.
WHAT HAPPENS IF HIV-INFECTED CHILDREN ARE UNTREATED?
If untreated, three-quarters (75%) of children who are infected through MTCT will develop problems from HIV and will die before the age of five.
For children who are infected through mother-to-child transmission and who do not receive any antiretroviral treatment or cotrimoxazole prophylactic therapy:
about one-third will die by one year of age, and half will die by two years of age.
Many of these infant deaths occur at home before presentation to health care facilities. Children with HIV infection can develop severe illness very quickly.
They may not present with the classic picture of chronic wasting and decline that is commonly seen in adults with HIV or AIDS. HIV/AIDS is rapidly fatal in children – this is why early HIV diagnosis essential.
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HOW CAN DEATHS FROM HIV BE PREVENTED IN CHILDREN?
Important interventions to reduce the risk of children dying from HIV includes:
1. Early diagnosis of HIV
2. Initiating Antiretroviral Therapy (ART) 3. Initiating other prophylaxis and treatments
Infants are most at risk of developing serious complications and dying from HIV infection – therefore it is most important that these children are identified, and placed on treatment. You will now read more in the following sections about each of these points for preventing deaths: early diagnosis through HIV testing, prophylaxis, treatments, and ART.
SELF-ASSESSMENT EXERCISE A – HIV TERMS
Define the following terms in a way that you would explain to a caretaker.
1. Immune system:
2. CD4:
3. Opportunistic infection:
8.3 HIV TESTING
What are the learning objectives for this section?
After you study this section, you will know how to:
• Explain the types of HIV tests available in your country
• Interpret the tests based on a child’s age, breastfeeding status, and mother’s status
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nOPENING CASE STUDY – PETER
Peter is 6 months old. His mother, Lungile, brought him to your clinic because he had cough for the last 3 days. Peter has no general danger signs. He breathes 54 per minute but he has no chest indrawing and no stridor or wheeze. He has no diarrhoea, fever, or ear problems. His weight is 7.2 kg. His temperature is 37.5 degrees. Lungile is worried. She was recently told she has HIV. She is receiving care at another clinic.
How will you assess and classify Peter?
First, you know that you will use the sick child charts because Peter is between 2 months and 5 years of age. You record Peter’s important information at the top of the recording form. You assess his cough: he has fast breathing but no other signs. You classify as PNEUMONIA. You do not classify for diarrhoea, fever, or ear problems. He is not low weight for age. Lungile tells you she breastfed Peter until he was 4 months old.
How will you record this information on Peter’s recording form?
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Temperature (°C):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign
present?
Yes ___ No ___
Remember to use Danger sign when
selecting classifications NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING CONVULSIONS
LETHARGIC OR UNCONSCIOUS CONVULSING NOW
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
For how long? ___ Days Count the breaths in one minute
___ breaths per minute. Fast breathing?
Look for chest indrawing Look and listen for stridor Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days
Is there blood in the stool? Look at the childs general condition. Is the child:
Lethargic or unconscious?
Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowsly (longer then 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __
Decide malaria risk: High ___ Low ___ No___
For how long? ___ Days
If more than 7 days, has fever been present every day?
Has child had measels within the last 3 months?
Do malaria test if NO general danger sign High risk: all fever cases
Low risk: if NO obvious cause of fever
Test POSITIVE? P. falciparum P. vivaxNEGATIVE?
Look or feel for stiff neck Look for runny nose Look for signs of MEASLES:
Generalized rash and
One of these: cough, runny nose, or red eyes Look for any other cause of fever.
If the child has measles now or within the last 3 months:
Look for mouth ulcers.
If yes, are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain?
Is there ear discharge?
If Yes, for how long? ___ Days
Look for pus draining from the ear Feel for tender swelling behind the ear THEN CHECK FOR ACUTE MALNUTRITION
AND ANAEMIA
Look for oedema of both feet.
Determine WFH/L _____ Z score.
For children 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:
Is there any medical complication?
General danger sign?
Any severe classification?
Pneumonia with chest indrawing?
For a child 6 months or older offer RUTF to eat. Is the child:
Not able to finish or able to finish?
For a child less than 6 months is there a breastfeeding problem?
CHECK FOR HIV INFECTION Note mother's and/or child's HIV status
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next immunization on:
________________
(Date) BCGOPV-0
Hep B0
DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1
DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2
DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3
Measles1 Measles 2 Vitamin A Mebendazole
Page 65 of 75
Lungile has told you she is HIV-infected. Now you will learn about HIV tests used for sick children and infants in your country.
WHY DOES HIV TESTING IMPORTANT FOR IMCI?
In order to assess and classify a child for HIV, you need to know if he or she has already had an HIV test.
Open your chart booklet and review the ASSESS and CLASSIFY table for HIV. You will see there are two sets of charts. These are based on whether or not the child has been tested for HIV. You will now learn about HIV tests, and then you will continue on to assessing and classifying.
WHEN IS IT NECESSARY TO TEST A CHILD FOR HIV?
You will encourage HIV testing for:
■
n All children born to an HIV-infected mother
■
n All children that do not have a known test result, and you do not know the mother’s status
■
n In a high HIV setting, every child who is sick should be tested for HIV
WHAT ARE HIV TESTS?
Different tests are available to diagnose HIV infection. It is first important to understand the different tests – some detect antibodies, and others detect the virus itself. The results from these two tests are understood differently. Review these two test types in the table:
What does the test detect? How can you interpret the test?
SEROLOGICAL TESTS including rapid tests
These tests detect antibodies made by immune cells in response to HIV.
They do not detect the HIV virus itself.
HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not disappear until the child is 18 months of age.
This means that a positive serological test in children under the age of 18 months is not a reliable way to check for infection of the child.
VIROLOGICAL TESTS including DNA or RNA PCR
These tests directly detect the presence of the HIV virus or products of the virus in the blood.
Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old.
If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected. Tests should be done six weeks or more after breastfeeding has completely stopped – only then do the tests reliably rule out infection.
Now you will read more about these tests and their relevance for different age groups:
children under 18 months, and 18 months or older.
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WHAT TEST SHOULD BE USED IF THE CHILD IS 18 MONTHS OR OLDER?
You will use a serological test to determine the HIV status of a child 18 months or older. If the serological test is positive it confirms the child’s status as HIV- infected.
WHAT TEST SHOULD BE USED IF THE CHILD IS UNDER 18 MONTHS OLD?
A virological test (PCR) is the only reliable method to determine the child’s HIV status below 18 months of age. It detects the actual virus in the child’s blood.
Remember that serological tests do not determine HIV status in this age group. This is because the test may detect antibodies that might have passed from the mother through the placenta. Therefore a positive serological test may only tell you that the child has been exposed to HIV, rather than that the child is HIV- infected.
THERE ARE TWO SCENARIOS FOR CHILDREN UNDER 18 MONTHS:
This depends on the availability of PCR in your country:
1. IF PCR or other virological TEST IS AVAILABLE, TEST FROM 4–6 WEEKS OF AGE
+ A POSITIVE result means that the child is infected, as it detects the actual presence of HIV in the child
– A NEGATIVE result means that child is not infected, but could become infected if they are still breastfeeding
2. IF PCR or other virological TEST IS NOT AVAILABLE, USE A SEROLOGICAL TEST
+ A POSITIVE result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected. All HIV-exposed infants should be tested using PCR or other virological test.
– A NEGATIVE result usually means the child is not infected. A negative test is also useful because it usually excludes HIV infection from the mother, as long as the child has not breastfed for more than 6 weeks.
HOW WILL YOU INTERPRET A SEROLOGICAL TEST IN A CHILD UNDER 18 MONTHS?
As you have read, the breast milk of an HIV-positive mother can transmit HIV. You see in the chart that this affects how you will interpret test results.
Is child breastfeeding? POSITIVE (+) test NEGATIVE (-) test NOT BREASTFEEDING, and
has not in last 6 weeks
HIV exposed and/or HIV infected – Manage as if they could be infected. Repeat test at 18 months.
HIV negative
Child is not HIV infected BREASTFEEDING HIV exposed and/or HIV infected –
Manage as if they could be infected. Repeat test at 18 months or once breastfeeding has been discontinued for more than 6 weeks.
Child can still be infected by breastfeeding.
Repeat test once breastfeeding has been discontinued for more than 6 weeks.
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REVIEW THE EARLY INFANT DIAGNOSIS ALGORITHM BELOW:
This flow charts help you make decisions about the testing course of action for children under 18 months. It provides some more specifics in addition to the information you read on the previous page.
Review the early infant diagnosis algorithm below:
This flow charts help you make decisions about the testing course of action for children under 18 months. It provides some more specifics in addition to the information you read on the previous page.
HIV-‐exposed Infant or child <18 months
Repeat antibody test at 18 months of age and/or 6 weeks after cessation of
breastfeeding
Positive Negative
Conduct diagnostic viral testa
Viral test available Viral test not available
Infant/child is likely infected
<24 months: immediately start ARTb
And repeat viral test to confirm infection
Never breastfed Ever breastfed or currently breastfeeding Infant/child is
uninfected Infant /child remains at risk for acquiring HIV infection until complete cessation of
breastfeedingc
Regular and periodic clinical monitoring
Infant/child develops signs or symptoms
suggestive of HIV Infant remains well and reaches 9 months of age
Conduct HIV antibody test at approximately 9 months of age Viral test not available
Viral test available
Viral test not available assume infected if sick assume uninfected if well
Positive Negative
Negative Positive
HIV unlikely unless still breastfeedingc Infant/child is infected
Start ARTb And repeat viral test to confirm
infection
sick well
a For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant diagnosis.
b Start ART, if indicated, without delay. At the same time, retest to confirm infection.
c The risk of HIV transmission remains as long as breastfeeding continues.
21
WHAT MOTHERS NEED TO BE COUNSELLED FOR THEIR CHILD’S HIV TEST?
Many mothers, and even health workers, are reluctant to discuss HIV.
However, HIV is present in the community and the problem will not be solved as long as there is secrecy surrounding the topic. The mother of a child classified as HIV EXPOSED will need to be counselled about an HIV test for the child. These children all require HIV tests and re-classification based on these tests.
WHAT INFORMATION SHOULD BE PROVIDED TO THE MOTHER?
When you have identified a young infant or child who is in need of HIV testing you should provide the mother with information:
• Explain why it is important to test the child (e.g. status is unknown).
• Help the mother to understand that the reason for HIV testing is so that the child can receive treatment that will improve his quality of life. He should have antibiotics to prevent infections, vitamin supplementation, regular growth monitoring, treatment of any illnesses, and antiretroviral therapy if needed. If the child is less than about 2 years, counsel on infant feeding.
HOW CAN YOU HELP ADDRESS A CAREGIVER’S CONCERNS?
Once you have explained, allow the mother to ask questions and address her concerns. If she agrees to the test, arrange it in the normal way at your clinic.
Since the most common route of HIV infection for a child is by mother-to-child transmission, you may need to discuss testing her and her partner as well perhaps even before testing the child.
Mother-to-child transmission presents a number of barriers to testing of the child. HIV may provoke feelings of guilt on the part of the mother, as well as fears of rejection by and of the child and of revealing their own HIV status and how they were infected. All health workers must be equipped with the knowledge and ability to discuss HIV, ask questions and give appropriate counselling.
WHAT SHOULD A HEALTH WORKER DO IF A MOTHER REFUSES TESTING?
If a mother does not agree to test the child, the health worker should listen to and address her concerns and reasons against testing. The health worker may be considered an advocate for the child and negotiate with the parent or carer in the child’s best interest. Reassurances should be made regarding treatment, care, support and/or preventive interventions that the child may benefit from once diagnosed. It may help for the parent/carer to express their concerns without the child’s presence.
WHAT STEPS SHOULD BE TAKEN AFTER TESTING?
After testing, make an appointment for a review of the results and post-test counselling. If a serological test has been performed, do the post-test counselling immediately if this is agreeable to the mother. Maintain privacy and confidentiality so that the mother can discuss her concerns freely.
After you explain information, allow the mother to ask questions.
Address her concerns.
SELF-ASSESSMENT EXERCISE B – HIV TESTING
Complete the following questions to practice what you have learned about HIV tests.
1. What is the difference between an HIV virological (PCR) test and an HIV serological test?
2. What test would you use to confirm HIV infection in a child under the age of 18 months?
3. A 20 month old baby has a positive virological (PCR) test. Is the child HIV infected?
4. A 2 month old breastfeeding baby has a positive HIV serological test. Is the child HIV infected?
5. A 2 month old baby has a positive virological (PCR) test. Is the child HIV infected?
6. A 21 month child has a negative serological test. Child has not breastfed since he was 6 months old. Is the child HIV infected?
7. An 18 month old breastfeeding child has a positive HIV serological test. Is the child HIV infected?
8. A 9 month old breastfeeding baby has a negative virological (PCR) test. Is the child HIV infected?
9. A 9 month old baby has a negative virological (PCR) test. The baby last breastfed 3 months ago. Is the child confirmed HIV negative?
10. A 16 month old child has a negative serological test. The child is not breastfeeding.
Is the child confirmed HIV negative?
23
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
Review the main points from this section. Reading this summary, and completing the self-assessment exercises in the module, are important for learning.
1. HIV testing is essential for assessing and classifying a child for HIV You will assess a child based on his HIV tests and clinical signs.
2. A positive serological HIV test cannot confirm HIV infection for children below 18 months. This is because the test shows the presence of antibodies – and children under 18 months can still have antibodies from their mothers.
However, a negative test is useful because it usually excludes HIV infection from the mother, so long as the child has not been breastfed for more than 6 weeks.
3. A positive serological HIV test cannot confirm HIV infection for children below 18 months. This is because the test shows the presence of antibodies, and children under 18 months may have antibodies present from their mothers.
4. Breastfeeding matters
A child can be infected with HIV through breast milk. An HIV test can only be confirmed once a child has stopped breastfeeding for at least 6 weeks.
8.4 ASSESS & CLASSIFY A SICK CHILD
What are the learning objectives for this section?
After you study this section, you will know how to:
• Assess a sick child for HIV by using their test results or clinical signs of HIV
• Classify a sick child for HIV
IN SUMMARY, HOW DO YOU KNOW WHEN A CHILD IS HIV INFECTED?
In the last section you learned about HIV testing, and how to interpret results by age group and by breastfeeding status. These test results will determine how you assess and classify the child or sick young infant.
SUMMARY: how do you know when a child is HIV infected?
n POSITIVE VIROLOGICAL (PCR) TEST at any age with a confirmatory test n POSITIVE SEROLOGICAL TEST at 18 months or older with a confirmatory test
Remember that test results are not confirmed unless child has not been breastfeeding for at least 6 weeks. Children can still be infected by breastfeeding.
HOW WILL YOU USE TEST RESULTS TO ASSESS?
To ASSESS a child for HIV, you will use: (a) test results, if available, and (b) clinical signs. The first step in assessing is to determine whether or not there are test results available for the child or mother. This will help determine your steps for ASSESSING.
For ALL sick children – ask the caretaker about the child’s problems, check for general danger signs, assess for cough or difficult breathing, assess for diarrhoea,
assess for ear problem, check for malnutrition and anaemia, and then:
ASK: HAS THE CHILD or MOTHER BEEN TESTED FOR HIV INFECTION?
YES, test results available NO test results available Assess for HIV infection Check for features of HIV
CLASSIFY the child using the colour-coded charts
Check immunization status, assess feeding, other problems and mother’s health
25
HOW WILL YOU ASSESS FOR HIV INFECTION?
Open to your ASSESS chart for HIV. It contains these instructions, starting with ASK:
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
ASK
Has the mother and/or
child had an HIV test? IF YES: Then note mother's and/or child's HIV status:-
Mother's HIV status: POSITIVE or NEGATIVE Child's HIV status:
Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE IF NO: Mother and child status unknown, then TEST mother.
If positive, then test the child.
If mother is HIV positive and child is negative or unknown, ASK:
Was the child breastfeeding at the time or 6 weeks before the test?
Is the child breastfeeding now?
If breastfeeding ASK: Is the mother and child on ARV prophylaxis?
Positive virological test in child
OR
Positive serological test in a child 18 months or older
Yellow:
CONFIRMED HIV INFECTION
Give cotrimoxazole prophylaxis* Give HIV care and initiate ART treatment Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Refer for TB assessment and INH preventive therapy
Follow-up regularly as per national guidelines Mother HIV-positive AND
negative virological test in child breastfeeding or if only stopped less than 6 weeks ago
OR
Mother HIV-positive, child not yet tested
OR
Positive serological test in a child less than 18 months old
Yellow:
HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended
Do virological test to confirm HIV status** Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Follow-up regularly as per national guidelines
Negative HIV test in mother
or child* Green:
HIV INFECTION UNLIKELY
Treat, counsel and follow-up existing infections Classify
HIVstatus
* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
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On the following pages, you will learn about each of these instructions.
ASK: HAS THE MOTHER AND/OR THE CHILD HAD AN HIV TEST?
Remember that this is sensitive information, and that it is important to ensure confidentiality.
All mothers should have been offered testing during their pregnancy. Ask the mother if she has had an HIV test. If the mother has had a test, ask her what the result was.
YES the mother or child has had an HIV test. Record the test results:
1. Mother’s HIV status: POSITIVE or NEGATIVE
Remember that a mother may have tested negative in the past, and could now be HIV infected. The more recent the test, the more likely it is to be accurate.
2. Child’s HIV status:
a. Virological test POSITIVE or NEGATIVE b. Serological test POSITIVE or NEGATIVE
NO test result is available for mother or child. Conduct an HIV test:
If there is no test available, you will test the mother. If the test is POSITIVE, then test the child. You learned in Section 3 of this module about the types of HIV tests available in your country. Remember tests are different depending on the child’s age:
• child 18 months or older: you will use a serological test. If the test is positive it confirms the child’s status as HIV-infected.
• child under 18 months: a virological test (PCR) is the only reliable method to determine the child’s HIV status. It detects the actual virus in the child’s blood.
IF MOTHER IS HIV POSITIVE AND CHILD IS NEGATIVE OR UNKNOWN
In this situation, you must ask more about the child’s feeding status. You remember that breast milk can transmit HIV. As a result, a child who has initially tested negative may still develop HIV infection.It is therefore important to know if the child was breastfeeding or had been breastfed in the six weeks before the test was done. Six weeks is considered the “window period” or time during which a patient may test negative even though they are infected.
In order to better understand the child’s feeding status, you will ask the following questions and record responses:
1. If a previous test was done, was the child breastfeeding at the time or the test?
Was the child breastfeeding in the 6 weeks before the test?
2. Is the child breastfeeding now?
3. If the child is breastfeeding, ASK: is the mother and child on ARV prophylaxis?
You will learn more about ARV prophylaxis in section 9.6.
REMEMBER! Child must not have breastfed within six weeks of a test in order for it to be confirmed negative.
27
WITH HIV RESULTS AVAILABLE, CLASSIFY THE CHILD:
Once you have the child or mother’s test results, you can classify according to the result. Open to the classification table. There are three classifications:
1. CONFIRMED HIV INFECTION 2. HIV EXPOSED
3. HIV INFECTION UNLIKELY
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
ASK
Has the mother and/or
child had an HIV test? IF YES: Then note mother's and/or child's HIV status:-
Mother's HIV status: POSITIVE or NEGATIVE Child's HIV status:
Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE IF NO: Mother and child status unknown, then TEST mother.
If positive, then test the child.
If mother is HIV positive and child is negative or unknown, ASK:
Was the child breastfeeding at the time or 6 weeks before the test?
Is the child breastfeeding now?
If breastfeeding ASK: Is the mother and child on ARV prophylaxis?
Positive virological test in child
OR
Positive serological test in a child 18 months or older
Yellow:
CONFIRMED HIV INFECTION
Give cotrimoxazole prophylaxis*
Give HIV care and initiate ART treatment Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Refer for TB assessment and INH preventive therapy
Follow-up regularly as per national guidelines Mother HIV-positive AND
negative virological test in child breastfeeding or if only stopped less than 6 weeks ago
OR
Mother HIV-positive, child not yet tested
OR
Positive serological test in a child less than 18 months old
Yellow:
HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended
Do virological test to confirm HIV status**
Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Follow-up regularly as per national guidelines
Negative HIV test in mother
or child* Green:
HIV INFECTION UNLIKELY
Treat, counsel and follow-up existing infections Classify
HIVstatus
* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
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CONFIRMED HIV INFECTION (YELLOW)
A child with a positive HIV test should be classified as CONFIRMED HIV INFECTION. This means a positive serological test for a child 18 months or older.
Virological tests confirm HIV in all children. These children should be provided cotrimoxazole prophylaxis (you will learn about eligibility in 9.6), HIV care and ART, and other counselling.
HIV EXPOSED (YELLOW)
Children born to HIV-positive women are HIV EXPOSED and could possibly have HIV. This classification is used for three different scenarios:
1. Mother is HIV-positive and the child has a negative virological test, but the child is still breastfeeding or stopped less than 6 weeks ago. Due to the breastfeeding, the child still risks exposure, or the negative status cannot yet be confirmed.
2. Mother is HIV-positive and child has not yet tested.
3. The child is less than 18 months old and has a positive serological test. Remember that this child’s status can only be confirmed with a virological test.
* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available, offer HIV testing for child.
These children require cotrimoxazole prophylaxis and ARV prophylaxis (as recommended). The child should receive a virological test to confirm status.
If this test is negative, it must be repeated after breastfeeding has stopped for 6 weeks in order to be confirmed.
HIV INFECTION UNLIKELY (GREEN)
If mother or child has a negative test, the child is classified HIV NEGATIVE. You will treat, counsel, and follow-up existing conditions according to your IMCI assessment.
SELF-ASSESSMENT EXERCISE C – ASSESS & CLASSIFY SICK CHILD
Are these statements about assessing and classifying true or false?
a. A 10-month old has a positive virological test. She stopped breastfeeding 30 days ago. She should be classified as CONFIRMED HIV INFECTION.
TRUE FALSE b. A 9 month old child is still breastfeeding has tested
negative with a PCR test. He should be classified as HIV INFECTION UNLIKELY.
TRUE FALSE c. A 9 week old child is clinically well. His mother is HIV-
infected. The child has not been tested yet, so you conduct a serological test. The result is positive. He should be classified as CONFIRMED HIV INFECTION.
TRUE FALSE
d. You send for a PCR test for a 16 month old. The results are positive. He stopped breastfeeding when he was 12 months old. He should be classified as CONFIRMED HIV INFECTION.
TRUE FALSE
e. A 4 month old was born to an HIV-infected mother. He is breastfeeding. You provide a serological test, and the result is positive. He should be classified as HIV EXPOSED.
TRUE FALSE f. An 8 month old child born to an HIV-infected mother
comes to the clinic. Her mother says she was tested 2 months ago. You see the PCR results, and they are negative. The child is still breastfeeding. She should be classified as HIV INFECTION UNLIKELY.
TRUE FALSE
g. A 36 month old child has a positive serological HIV test.
She should be classified as CONFIRMED HIV INFECTION. TRUE FALSE
29
nHow will you assess Peter for HIV?
First, you review the ASSESS table in the sick child charts. You ask Lungile is Peter is breastfeeding. She says yes. She has also already told you that she has been tested for HIV and is infected. She did not receive any ART prophylaxis for PMTCT.
You ask if Peter has been tested, and she says no. You counsel Lungile on testing Peter for HIV, and the importance of identifying children who are exposed or infected with HIV. You provide a serological test. The result is positive.
n
How will you classify Peter?
Lungile is HIV positive, and Peter has a negative serological test. He is 6 months old. You classify him as HIV EXPOSED.
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
1. You will use HIV test results from a child and mother to assess and classify a child’s HIV status. You will use test results from a mother and/
or child to classify the child’s HIV status. The first course of action is to test the mother if you do not have her test results. If she is positive, then you will test the child. It is important to maintain confidentiality of the test results of mothers and children. If the HIV status of the mother or child is unknown, the care provider should offer HIV testing especially if the child has malnutrition, pneumonia, diarrhoea, chronic cough or other symptoms that may suggest HIV/
AIDS. This is referred as provider-initiated testing and counseling.
2. Children can be infected with HIV while breastfeeding. Test results cannot be confirmed unless the child has not breastfed for 6 weeks or more. This is an important window.
Remember that you cannot confirm Peter’s HIV status until he has stopped breastfeeding for at least 6 weeks. His status must be confirmed with a virological test as long as he is under 18 months of age.
In section 6 you will learn how to give prophylaxis to Peter. In section 7 you will learn about feeding recommendations for Peter. In section 8 and subsequent sections you will learn about follow-up care, including ART initiation if the child is confirmed positive. With the classification HIV EXPOSED, Peter will follow-up with you monthly.
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
ASK
Has the mother and/or
child had an HIV test? IF YES: Then note mother's and/or child's HIV status:-
Mother's HIV status: POSITIVE or NEGATIVE Child's HIV status:
Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE IF NO: Mother and child status unknown, then TEST mother.
If positive, then test the child.
If mother is HIV positive and child is negative or unknown, ASK:
Was the child breastfeeding at the time or 6 weeks before the test?
Is the child breastfeeding now?
If breastfeeding ASK: Is the mother and child on ARV prophylaxis?
Positive virological test in child
OR
Positive serological test in a child 18 months or older
Yellow:
CONFIRMED HIV INFECTION
Give cotrimoxazole prophylaxis*
Give HIV care and initiate ART treatment Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Refer for TB assessment and INH preventive therapy
Follow-up regularly as per national guidelines Mother HIV-positive AND
negative virological test in child breastfeeding or if only stopped less than 6 weeks ago
OR
Mother HIV-positive, child not yet tested
OR
Positive serological test in a child less than 18 months old
Yellow:
HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended
Do virological test to confirm HIV status**
Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care
Follow-up regularly as per national guidelines
Negative HIV test in mother
or child* Green:
HIV INFECTION UNLIKELY
Treat, counsel and follow-up existing infections Classify
HIVstatus
* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
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3. Virological tests must be used to confirm the status of a child under 18 months. Children under 18 months require confirmation by PCR (virological) testing. Remember it is different for children older than 18 months: these children can be confirmed with a serological test. The second important point is that test results cannot be confirmed unless the child has not breastfed for 6 weeks or more.
31
8.5 ASSESS & CLASSIFY A SICK YOUNG INFANT
What are the learning objectives for this section?
• Explain how assessing and classifying for HIV is different for a young infant
• Assess and classify a young infant using the chart booklet
WHEN WILL YOU ASSESS AND CLASSIFY A YOUNG INFANT FOR HIV?
Review what you have learned so far about assessing and classifying the sick young infant.
HOW IS ASSESSING AND CLASSIFYING A YOUNG INFANT DIFFERENT THAN A CHILD?
Assessing and classifying the sick young infant for HIV differs from the classification for an older child. It is not possible to classify the sick young infant for SYMPTOMATIC HIV INFECTION because infants usually do not show signs and symptoms of HIV like children.
Young infants with HIV infection usually do not have any signs and symptoms directly related to HIV infection – this does not mean that they may not become ill, but rather that they will develop signs and symptoms of common childhood illnesses such as pneumonia or diarrhoea. As a result, the assessment and classification of HIV infection in young infants is based on HIV test results.
For ALL sick young infants – ask the caretaker about the infant’s problems, check for signs of possible bacterial infection and jaundice, assess for diarrhoea, then:
ASK: HAS INFANT BEEN TESTED FOR HIV?
YES NO
Assess for HIV infection Assess based on mother’s status CLASSIFY the young infant’s HIV status using the colour-coded charts
NEXT: assess for feeding problems or low weight, check immunizations, consider special risk factors, and assess mother’s health and other problems
Young infants usually do not have signs directly related to HIV.
As a result, classifications use HIV test results.
