DR NISHANT PRABHAKARMD PEDIATRICS

Infant and child born to HIV infected woman, are reliably excluded or confimed with HIV status and the infant or child is no longer exposed to HIV through breast feeding.

Immediate Care at Birth Infant feeding ARV prophylaxis Cotrimoxazole prophylaxis (CPT) Immunization and Vitamin A

Supplementation Growth and Development Early infant diagnosis Follow up

Follow universal precautions. Do not milk the cord. The cord should be clamped soon after

birth. Cover the cord with gloved hand and

gauze before cutting to avoid blood splattering.

Initiate breast feeding within the first hour of birth in accordance with the preferred and informed choice of the mother.

1. Either maternal or infant ARV prophylaxis during the duration of breast feeding.

2. Exclusive breast feeding is the recommended infant feeding choice in the first 6 months, irrespective of whether mother or infant is provided with ARV drugs for the duration of breastfeeding.

3. MIXED FEEDING SHOULD NOT BE DONE AT ANY COST WITHIN THE FIRST 6 MONTHS.

4 Only in situations where breastfeeding cannot be done or on individual parents' informed decision, then replacement feeding may be considered.

AFASS criteria for Exclusive Replacement Feeding

A- Acceptability F- Feasibility A- Affordability- sufficient replacement feeding S- Safe water & sanitation S- Sustainability= un-interrupted feeding for

atleast 6 months.

5 - Exclusive breastfeeding for at least 6 months- complementary feeding should be introduced GRADUALLY, irrespective of infant HIV status by EID.

6 - Mother should be receiving ARV prophylaxis or ART during the whole duration of breastfeeding. ARV prophylaxis should continue for one week after the breastfeeding has fully stopped.

7 - For breastfeeding infants diagnosed HIV negative, breastfeeding should be continued until 12 months of age irrespective of whether the mother is on ART or ARV prophylaxis

8 - After 6 weeks of stopping breast feeds, repeat EID. Confirmation test for HIV has to be done at 18 months irrespective of the EID status.

9- For breastfeeding infants diagnosed HIV positive, paediatric ART should be started and breastfeeding should be continued till 2 years of age.

10 - Breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided.

All Infants born to women who are receiving ART / maternal triple ARV prophylaxis / who present directly-in-labor and receive intra partum ARV prophylaxis should be started on daily NVP prophylaxis at birth and continue for a minimum of 6 weeks, regardless of whether the infant is exclusively breastfed or receives replacement feeding.

Infants born to women who present directly-in-labor and receive intra partum ARV prophylaxis, NVP prophylaxis should not be stopped at 6 weeks of life but continued until the mother initiated on ART/ARV prophylaxis and complete a minimum of six weeks of therapy.

All HIV-exposed infants should receive CPT from the age of 6 weeks until HIV is reliably excluded.

In all those confirmed to be HIV-infected, it should be continued till 5 years of age. The recommended dose is 5 mg/kg/day of TMP once daily.

Children with severe adverse reaction (grade 4 reaction) to Cotrimoxazole or with G6PD deficiency should not be initiated on CPT. The alternative drug is Dapsone 2 mg/kg once daily (max. 100 mg/day) orally.

Aerolised pentamidine for children > 5 years

administered via respigard II inhaler in the dose of 300 mg once a month is another alternative.

Dosage: 5mg/kg of TMP/day orally once daily *splitting of tablets into quarters is not recommended, unless there is no syrup available.

Live vaccines should be avoided in all severely immune compromised infants (CD4 %< 25% or WHO stage 3 and 4).

Vitamin A supplementation should be as per the national immunization schedule. National Immunization schedule is as follows:

If the child’s growth curve is falling down, flattening or faltering, reinforce nutrition and urgent assessment for nutrition status, HIV related features and screen for treatable causes e.g. nutritional deficiency & chronic infections.

For the children on ART with growth flattering or decline, look for treatment failure.

Delayed development or loss of milestones after attaining them (Regression of Milestones), may be the first sign of HIV infection suggesting HIV encephalopathy

Maternal HIV antibody transferred passively during pregnancy can persist for as long as 18 months in children born to HIV-infected mothers. Hence, positive HIV antibody test does not necessarily indicate HIV infection in the infant/child. In children who are breastfed, since they have ongoing risk for HIV transmission, HIV infection can only be excluded after 6 weeks of complete cessation of breastfeeding.

In the current Early Infant Diagnosis (EID) program, virological tests i.e. HIV-1 DNA PCR by Dried Blood Spot (DBS) and on Whole Blood Sample (WBS) are being done for infants and children below 18 months of age. Antibody tests, using rapid test method can be used for children > 18 months of age for diagnosis of HIV infection as in adults.

Previous algorithm A & B have been merged.

Confirmatory whole blood test has been replaced by a confirmatory second dry blood spot (DBS) test. First DBS has to be done in regional reference lab on being HIV-1 reactive second DBS has to be sampled at ICTC.

All the exposed children included in EID algorithm irrespective of HIV status as per molecular test has to be confirmed at 18 months as per national algorithm.

first follow up visit should be at 2 weeks of age for babies on ARV prophylaxis to look for any adverse reaction to NVP.

Rest follow up visit at the ICTC centre are as per following table.

Appropriate counselling would include- counseling on PPTCT, ARV prophylaxis, infant feeding, nutrition, EID, CPT initiation, vaccination, opportunistic infections, ART therapy and adherence