Base Line Investigations for Children with HIV

Submitted by Paul Decle on Fri, 05/08/2011

Authors: Guide information
Hermione Lyall Date of preparation: June 2003
Date reviewed: March 2011
Next review date: March 2012
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Contents

First Line HIV Diagnostic Tests
Second Line Confirmatory HIV Tests and Assessment of Severity of HIV Disease
PCP Prophylaxis

Baseline investigations for suspected HIV in an infant/child, or at first visit of a child known to have HIV

If history and examination lead to a differential diagnosis, which includes HIV, pay special attention to:

History

Birth:

mode of delivery; duration of rupture of membranes;
birth weight; infant feeding; maternal health; and antenatal HIV test result.

Past Medical History:

previous infections (including oral candida); swollen lymph nodes; chronic diarrhoea; failure to thrive;
recurrent URTI's; childhood exanthems (e.g. chickenpox, rubella); severe infections; hospitalisations; transfusions and IM injections; TB exposure; immunisations; developmental history; and sexual history (if appropriate).

Social History:

name and relationship of adult accompanying child; who has parental responsibility; deaths of parents or siblings; significant previous caregivers; travel history; housing; and social circumstances.

Drug history

previous antiretroviral exposure: in-utero/ peripartum/ as treatment in another country. Other current drugs. Children newly arrived from abroad may be on combination antiretroviral tablets not available in this country e.g. "Triommune" or "Stalanev" (both fixed dose combination tablets which contain stavudine + lamivudine + nevirapine), check with a specialist HIV pharmacist.

Examination:

Full examination including: mouth; lymph nodes; parotids; chest; liver; spleen; skin; neurology; growth (ht, wt, OFC); pubertal stage; and BCG scar.

First Line HIV Diagnostic Tests:

Infant < 18mths of Age

HIV antibody test & HIV DNA PCR

Child > 18mths

HIV antibody test

Second Line Confirmatory HIV Tests and Assessment of Severity of HIV Disease:
(If HIV known or clinically very likely then do both first and second line tests together)

HIV parameters

CD4 count
HIV RNA PCR (viral load)
Base line HIV resistance (+ maternal resistance if an infant)
HLA B5701

Haematology

FBC + film
Sickle screen (if appropriate racial group)
Ferritin
Consider malaria film if recently arrived from endemic area

Biochemistry

  U+E, Creat Total Protein (Globulin)
Ca, PO4 Albumin
LFT's Lipids
Glucose Amylase
TSH Vitamin D

Serology

Hepatitis A IgG, HBsAg, anti-HBsAg, HCV IgG, Syphilis serology
IgG for EBV, CMV, HSV, VZV, Toxoplasmosis

In children over 1 year: Measles, Mumps, Rubella IgG
Immunisation responses: H influenzae b, Tetanus (under 18 mths, serology may reflect maternal antibodies, and should be repeated)

Viral PCRs

Plasma CMV PCR should be undertaken in infants & children with advanced disease

HCV PCR - should be undertaken in infants at risk of exposure and those with advanced disease (this can be positive even if the child is HCV antibody negative)

Cultures

According to symptoms / travel history:

Stools / Urine / Throat swabs / Blood cultures / malaria films / gastric washings also for TB - Mantoux test (also consider IGRA if available) / sexual health screen if appropriate

Clinical Investigations

Formal ophthalmological examination for infants and children
with advanced disease
BP, Urinalysis, Height / Weight / Head circumference

Radiology

Baseline CXR
Bone age if small for age
Infants / children with neurological signs: MRI of brain

Development Assessment

Formal baseline development assessment where available

PCP Prophylaxis:

Infant < 12mths of age

If under 12 months of age, start Co-trimoxazole irrespective of CD4 count

Children > 1 year of age

Start Co-trimoxazole
1-4 yrs – CD4 count <20% or <500 x 106/L
5 yrs or older- CD4 count <15% or < 200 x 106/L

Assess the child's clinical stage according to WHO and/or CDC criteria (see PENTA 2009 guideline below)

Calculate the child's risk of progression to AIDS or death using the PENTA calculator (http://www.hppmcs.org/)

Use PENTA 2009 guidelines to decide whether the child is eligible to start antiretroviral treatment (http://www.pentatrials.org)

Discuss with network link centre (http://www.chiva.org.uk/professionals/health/networks/index.html)