Doctors Revision

IMCI · Age: 2 months - 5 years

HIV Exposed

Classification for an infant or child (<18 months) born to an HIV-positive mother who has not yet had definitive HIV testing (or had a negative DNA PCR while still breastfeeding/recently stopped) OR has a positive antibody test (<18m). Requires co-trimoxazole prophylaxis, linkage for EID testing, and specific feeding counselling.

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Care priority and warning signs

Care priority

Link to Care / Initiate Prophylaxis / Schedule Testing

Red flags

  • Any signs of illness (needs assessment per IMCI).
  • Poor growth or development.
  • Signs suggestive of HIV infection (thrush, recurrent infections etc.).

Assessment

  • Ask: Has the mother had an HIV test? (Mother is HIV-positive).
  • Ask: Has the child had an HIV test?
  • Determine child's status based on tests and age:
  • Case 1: Mother HIV+ AND child had negative DNA PCR test while breastfeeding or stopped < 6 weeks ago.
  • Case 2: Mother HIV+ AND child not yet tested.
  • Case 3: Mother HIV+ AND child < 18 months had positive serological (antibody) test.
  • Ask: Is the child breastfeeding now?
  • Ask: Is the mother on ART and child on ARV prophylaxis (if breastfeeding)?

Classification

  • (Mother HIV-positive AND Negative DNA PCR test in breastfeeding child or stopped < 6 weeks ago) OR (Mother HIV-positive AND Child not yet tested) OR (Mother HIV-positive AND Positive serological test in infant < 18 months) -> HIV EXPOSED

Key features

  • Child born to HIV-positive mother.
  • Child's definitive HIV status is not yet confirmed negative (either untested, inconclusive test timing relative to breastfeeding, or positive antibody test <18m which reflects maternal antibodies).
  • Requires co-trimoxazole prophylaxis until definitive negative status confirmed after breastfeeding cessation.
  • Requires timely EID testing (DNA PCR).
  • Requires specific counselling on safe infant feeding (AFASS criteria if considering stopping breastfeeding).

Management

Non-pharmacological management

  • Assess feeding and provide appropriate counselling based on mother's choice and circumstances (breastfeeding vs replacement feeding - counsel on AFASS criteria Page 28 if considering stopping breastfeeding).
  • Link child to ART/Mother Baby care point for follow-up, ARV prophylaxis (if breastfeeding), and EID testing.
  • Monitor growth and development.
  • Assess for TB (see page 9).

Pharmacological treatment

  • Give Co-trimoxazole prophylaxis daily. Start at 6 weeks of age (or at first contact if older). Dose: Age 6 weeks - 6 months: 2.5ml syrup (or 1 infant tab). Age >6 months - 5 years: 5ml syrup (or 1 adult tab/2 infant tabs). Continue until HIV infection definitively excluded after cessation of breastfeeding.
  • Ensure child receives appropriate ARV prophylaxis according to national PMTCT guidelines (especially if breastfeeding).
  • Perform DNA PCR test to confirm HIV status at appropriate time points (e.g., 6 weeks, after breastfeeding cessation - follow national EID algorithm). If DNA PCR is positive -> Confirmed HIV Infection. If negative after breastfeeding cessation -> HIV Infection Unlikely.
  • Ensure immunizations are up-to-date (follow schedule, give BCG at birth unless symptomatic).

Follow-up

  • Regular follow-up at Mother-Baby care point/ART clinic for EID testing, monitoring, ARV prophylaxis refills, and continued co-trimoxazole.
  • Final HIV test (usually rapid test) around 18-24 months or after breastfeeding cessation to confirm status.

Counselling points

  • Explain the meaning of 'HIV Exposed' - child needs testing to know status.
  • Explain the importance of daily Co-trimoxazole prophylaxis.
  • Explain the importance of ARV prophylaxis for the baby if breastfeeding.
  • Provide detailed counselling on safe infant feeding options (exclusive breastfeeding for first 6 months is generally recommended for exposed infants in resource-limited settings if mother is on ART; discuss stopping breastfeeding and AFASS criteria - page 28). Emphasize exclusive feeding method.
  • Explain the schedule for EID testing (DNA PCR).
  • Counsel on importance of mother's own health and ART adherence.
  • Advise on assessing for TB.
  • Advise on signs of illness requiring immediate care.

Differential diagnosis

  • Confirmed HIV Infection
  • HIV Infection Unlikely

Complications

  • Risk of acquiring HIV infection if PMTCT is suboptimal.
  • Increased risk of common childhood illnesses.
  • Side effects of prophylactic medications (rare).

Prevention

  • Effective PMTCT including maternal ART.
  • Infant ARV prophylaxis.
  • Safe infant feeding practices.
  • Co-trimoxazole prophylaxis.

References

IMCI Chart Booklet - Page 8, Page 9 (TB check), Page 14 (Co-trimoxazole), Pages 25-28 (Feeding, AFASS)

For learning and professional reference. Use current local guidance and clinical judgement.

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