HIV AIDS infection in infants

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The use of ART during pregnancy in HIV-infected women has resulted in a dramatic decrease in the transmission rate to infants, which is currently less than 2% in the United States, and the number of infants with AIDS in the United States continues to decline. Finally, children living with HIV infection are, as a group, growing older, bringing new challenges of adherence, drug resistance, reproductive health planning, management of multiple drugs, and long-term complications from HIV and its treatments.

Unique properties of HIV infection in pediatric age group

• Acquisition of infection through perinatal exposure for most infected children;
• In utero, intrapartum, and/or postpartum neonatal exposure to zidovudine and other ARV drugs in most perinatally infected children.
• Requirement for use of HIV virologic tests to diagnose perinatal HIV infection in infants younger than 18 months.
• Age-specific differences in CD4 cell counts.
• Changes in pharmacokinetic (PK) parameters with age caused by the continuing development and maturation of organ systems involved in drug metabolism and clearance.
• Differences in the clinical and virologic manifestations of perinatal HIV infection secondary to the occurrence of primary infection in growing, immunologically immature persons.
• Special considerations associated with adherence to ARV treatment for infants, children, and adolescents.

Recommendations

Diagnosis of HIV Infection in Infants

• Virologic assays that directly detect HIV must be used to diagnose HIV infection in infants younger than 18 months (AII). HIV antibody testing cannot establish HIV infection in this age group because maternal HIV antibodies may persist and interfere with the interpretation of a positive HIV antibody test.
• Virologic diagnostic testing is recommended in infants with known perinatal HIV exposure at ages 14–21 days, 1–2 months, and 4–6 months ( AII ).
• Virologic diagnostic testing at birth should be considered for infants at high risk of HIV infection (BIII).
• HIV DNA polymerase chain reaction (PCR) and HIV RNA assays are recommended as preferred virologic assays (AII).
• Confirmation of HIV infection should be based on two positive virologic tests obtained from separate blood samples (AI).
• Definitive exclusion of HIV infection (in the absence of breastfeeding) should be based on at least two negative virologic tests (one at >1 month and one at ≥4 months of age) (AII).
• Some experts confirm the absence of HIV infection at 12–18 months of age in infants with prior negative virologic tests by performing an antibody test to document loss of maternal HIV antibodies (BIII).
• In children ≥18 months of age, HIV antibody assays alone can be used for diagnosis (AII)

Laboratory Monitoring of Pediatric HIV Infection Before Initiation of Therapy

• The age of the child must be considered when interpreting the risk of disease progression based on CD4 percentage or count and plasma HIV RNA level (AII). For any given CD4 percentage or count, younger children, especially those in the first year of life, face higher risk of progression than do older children.
• In children younger than 5 years of age, CD4 percentage is preferred for monitoring immune status because of age-related changes in absolute CD4 count in this age group (AII).
• CD4 percentage or count should be measured at the time of diagnosis of HIV infection and at least every 3-4 months thereafter (AIII).
• Plasma HIV RNA should be measured to assess viral load at the time of diagnosis of HIV infection and at least every 3-4 months thereafter (AIII).
• More frequent CD4 cell and plasma HIV RNA monitoring should be considered in children with suspected clinical, immunologic, or virologic deterioration or to confirm an abnormal value (AIII).