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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)