Rubella

Paediatric HIV is usually acquired vertically during pregnancy, delivery or breastfeeding. Without treatment, infants can progress rapidly because of high viral replication and immature immune responses.

Early diagnosis and prompt antiretroviral therapy markedly reduce mortality and opportunistic infection risk.

Many children are initially asymptomatic.

Clinical clues include:

• Failure to thrive
• Recurrent or severe bacterial infections
• Persistent oral candidiasis
• Chronic diarrhoea
• Persistent generalized lymphadenopathy
• Parotid enlargement
• Recurrent pneumonia
• Tuberculosis
• Chronic skin disease
• Developmental delay or regression
• Hepatosplenomegaly
• Severe malnutrition

Advanced disease may present with Pneumocystis pneumonia, severe recurrent bacterial infection, disseminated TB or neurological disease.

In children younger than 18 months, maternal antibody makes standard antibody testing unreliable for definitive diagnosis.

Use virological testing, usually HIV nucleic acid testing, for definitive diagnosis in exposed infants.

In children 18 months or older, standard HIV serological testing algorithms can generally be used.

At diagnosis assess:

• Viral load
• CD4 count or percentage where indicated
• FBC
• Renal and liver function
• TB screening
• Nutritional status
• Immunization status
• Opportunistic infections

Start antiretroviral therapy promptly after diagnosis unless a specific opportunistic infection requires carefully timed initiation.

Current WHO guidance retains dolutegravir based therapy as the preferred foundation of first line treatment for children when age and weight appropriate formulations are available.

A typical regimen is:

Abacavir or tenofovir plus lamivudine plus dolutegravir, with exact backbone selected according to age, weight, renal function, prior exposure and national guidance.

Dose using current paediatric weight bands and formulations rather than extrapolating adult doses.

Provide co trimoxazole prophylaxis according to age, exposure status and immunological criteria.

Screen aggressively for TB.

Treat malnutrition, anaemia and opportunistic infections.

Monitor:

• Viral load
• Growth
• Adherence
• Drug toxicity
• Development
• Treatment failure

Persistent viraemia should trigger assessment of adherence, dosing, drug interactions and resistance before regimen change.