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Pediatrics & Child Health

IMCI Approach: HIV Check (2m-5y)

Assessment and classification of HIV status or exposure in children aged 2 months to 5 years using the IMCI approach, guiding further testing and linkage to care.

Also known as: Childhood HIV Assessment

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Referral and warning signs

When to refer

Refer ALL children with Confirmed HIV Infection OR classified as HIV Exposed to an ART/HIV care clinic for comprehensive management and follow-up. Refer any child with suspected HIV (based on clinical signs if testing unavailable) for testing and assessment.

Red flags

  • Any General Danger Sign in an HIV-exposed or infected child.
  • Signs of severe opportunistic infection (e.g., severe respiratory distress suggesting PCP).
  • Severe Acute Malnutrition.
  • Neurological regression.

Signs and symptoms

  • Ask:
  • - Is the child already enrolled in HIV care?
  • - If not: Has the mother or child had an HIV test?
  • - If yes: Determine mother's status (Positive/Negative) and child's test result (Virological Positive/Negative; Serological Positive/Negative).
  • - If mother positive & child negative/unknown: Was child breastfeeding at time of test or <6 weeks before? Is child breastfeeding now? Are mother/child on ARV prophylaxis?
  • Assess for Clinical Signs Suggestive of HIV (Consider if status unknown/negative but child unwell): Recurrent severe infections, poor growth, chronic diarrhoea, persistent oral thrush, generalized lymphadenopathy, etc. (These are NOT used for IMCI classification but may prompt testing).

Risk factors

  • Mother living with HIV.
  • Lack of PMTCT interventions.
  • Breastfeeding from untreated mother.
  • Blood transfusion (rare with screening).

Diagnosis

Clinical assessment

Classification based primarily on documented maternal and child HIV test results (considering type of test and timing relative to breastfeeding exposure).

Investigations

  • HIV Testing Strategy:
  • - If Mother's status unknown: Test mother first (Rapid Serological Test).
  • - If Mother Positive, Child status unknown:
  • - Age < 18 months: Virological Test (DNA PCR).
  • - Age >= 18 months: Serological Test (Rapid Antibody Test).
  • - Re-testing after breastfeeding cessation: If child tests negative while breastfeeding or <6 weeks after stopping, repeat test 6 weeks after complete cessation of breastfeeding.
  • CD4 count / Viral Load (for monitoring infected children - referral level).

Diagnostic criteria

IMCI Classification based on test results: - Confirmed HIV Infection: Positive Virological test (any age) OR Positive Serological test (age >=18 months). - HIV Exposed: Mother HIV positive AND (Negative virological test in breastfeeding child OR Child not yet tested OR Positive serological test <18 months). - HIV Infection Unlikely: Negative HIV test in mother OR Negative serological test in child >=18 months (and no ongoing exposure).

Management

Non-pharmacological management

  • Confirmed HIV Infection: Linkage to comprehensive HIV care and ART clinic. Nutritional assessment and support. Psychosocial support.
  • HIV Exposed: Counsel mother on infant feeding (support exclusive breastfeeding with maternal ART, or safe replacement). Support maternal ART adherence. Linkage to care for ongoing monitoring and testing. Counsel on preventing transmission.
  • HIV Infection Unlikely: Provide routine child care, immunizations, nutrition counseling.

Pharmacological treatment

  • Confirmed HIV Infection:
  • - Initiate lifelong ART immediately (follow current National ART Guidelines).
  • - Give Cotrimoxazole Prophylaxis: Dose based on age/weight (e.g., Age 2m-5y: 240mg tab - 1 tab OD if <14kg, 2 tabs OD if >=14kg). Continue lifelong or as per guidelines.
  • - Assess and provide Isoniazid Preventive Therapy (IPT) if eligible (See TB guidelines).
  • HIV Exposed:
  • - Give Cotrimoxazole Prophylaxis: Start at 6 weeks, continue until HIV infection excluded 6 weeks after breastfeeding cessation.
  • - Ensure infant ARV prophylaxis completed as per PMTCT guidelines.
  • - Ensure maternal ART adherence.

Monitoring

Regular follow-up for HIV-exposed and infected children as per national guidelines. Monitor growth, development, adherence to medications, CD4/VL (if infected). Repeat HIV testing for exposed infants at appropriate intervals.

Complications

  • Opportunistic infections (PCP, TB, severe bacterial infections).
  • Malnutrition / Failure to thrive.
  • Neurological impairment.
  • Malignancies.
  • Chronic lung disease.
  • Cardiomyopathy.

Prevention

  • PMTCT interventions (maternal testing, ART, infant prophylaxis, safer feeding).

Patient education

  • Explanation of HIV status (exposed vs infected vs unlikely).
  • Importance of ART for infected children (lifelong).
  • Importance of Cotrimoxazole prophylaxis (duration).
  • Infant feeding counseling.
  • Need for regular follow-up and monitoring.
  • Disclosure support.
  • Prevention of transmission.

Uganda-specific notes

Provider-initiated testing and counseling (PITC) is policy. Early Infant Diagnosis (EID) using DNA PCR from 6 weeks is standard. Cotrimoxazole prophylaxis for all HEI is critical. Linkage to and retention in care are key challenges.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17, Section 17.3.8 (IMCI Check); Chapter 3 (HIV sections)

  • IMCI Chart Booklet, MOH Uganda

    (HIV Check Algorithm)

  • Consolidated Guidelines for Prevention and Treatment of HIV in Uganda, MOH

    (Current National PMTCT/ART/EID protocols)

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