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Care priority and warning signs
Care priority
Link to Care / Initiate Prophylaxis / Schedule Testing
Red flags
- Any signs of PSBI/Very Severe Disease.
- Signs suggestive of HIV infection (thrush, poor growth etc.).
- Mother not on ART or infant not receiving ARV prophylaxis (high transmission risk).
Assessment
- Ask: Has the mother had an HIV test? (Mother is HIV-positive).
- Ask: Has the infant had an HIV virological test (DNA PCR)? (If yes, was it negative? When was it done relative to breastfeeding?)
- Determine infant's status based on mother's status and infant testing:
- Case 1: Mother HIV+ AND infant not yet tested.
- Case 2: Mother HIV+ AND infant had negative DNA PCR but exposure (breastfeeding) is ongoing or stopped < 6 weeks ago.
- Ask: Is the infant breastfeeding?
- Ask: Is mother on ART and infant on ARV prophylaxis?
Classification
- (Mother HIV positive AND negative virological test in infant who is breastfeeding or stopped less than 6 weeks ago) OR (Mother HIV positive, young infant not yet tested) -> HIV EXPOSED: POSSIBLE HIV INFECTION
Key features
- Infant born to HIV-positive mother.
- Infant's HIV status not confirmed negative post-exposure.
- Requires Co-trimoxazole prophylaxis from 6 weeks.
- Requires infant ARV prophylaxis as per national PMTCT guidelines.
- Requires timely EID testing (DNA PCR) at 6 weeks and after breastfeeding cessation.
- Requires specific counselling on safe infant feeding.
Management
Non-pharmacological management
- Link infant to Mother-Baby care point / PMTCT services for follow-up, ARV prophylaxis, and EID testing.
- Assess feeding and provide counselling on safe infant feeding options (Exclusive breastfeeding recommended for first 6 months if mother adherent to ART and infant receiving prophylaxis; discuss replacement feeding risks/benefits - follow national guidelines).
- Assess for TB.
- Monitor growth.
Pharmacological treatment
- Start Co-trimoxazole prophylaxis from 6 weeks of age. Dose: 2.5ml syrup (or 1 infant tab) daily. Continue until HIV excluded after breastfeeding cessation.
- Ensure infant receives appropriate ARV prophylaxis (e.g., Nevirapine or Zidovudine) daily from birth for duration recommended by national guidelines (e.g., 6 weeks or duration of breastfeeding).
- Perform DNA PCR test at 6 weeks of age. If positive -> Confirmed HIV Infection. If negative, continue prophylaxis and re-test after breastfeeding cessation.
- Treat any current illness according to IMCI guidelines.
- Ensure immunizations are up-to-date (give BCG at birth unless symptomatic).
Follow-up
- Regular follow-up at Mother-Baby care point for EID testing, ARV prophylaxis, co-trimoxazole, feeding support, growth monitoring.
- Definitive testing after breastfeeding cessation.
Counselling points
- Explain 'HIV Exposed' status and need for testing.
- Explain importance of daily Co-trimoxazole starting at 6 weeks.
- Explain importance of daily infant ARV prophylaxis.
- Provide detailed counselling on safe infant feeding (exclusive breastfeeding preferred if mother on ART, or safe replacement feeding).
- Explain EID testing schedule.
- Counsel on 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 HIV transmission.
- Increased risk of common illnesses.
Prevention
- Effective PMTCT.
- Infant ARV prophylaxis.
- Safe infant feeding.
- Co-trimoxazole.
References
IMCI Chart Booklet - Page 36 (Classification), Page 37 (Management Principles), Page 14 (Co-trimoxazole reference)