T·f SOU HfHN MHICAN JOUHNAL O~ HI MEOICl f ------------ AUGUST 200 I CLINICAL GUIDELINE Recommendations for best practice under ideal and resource-constrained conditions Clinical acumen should prevail in interpreting HIV test results, for example HIV infection can be ruled out in children 18 months of age or older who have negative HIV serology, a history of no breast-feeding or breast-feeding that ceased at least 3 months previously, no clinical symptoms of HIV disease and no hypo- or hypergammaglobulinaemia' In turn, all women should be encouraged to undergo voluntary counselling and testing lVcn' When HIV-exposed infants and young children have been identified, health care professionals still need to determine whether they are indeed HIV-infected or not. Such information is critical for the implementation of adequate medical care that mUSl address monitoring of T-cell subsets, lhe viral load and institution 0 warranted prophylaclic therapies." An N-uninfemd in'an child can 2. DEFINITION OF AN HN-UNINFECfED INFANT/CHILD Nonetheless, perinatal HIV diagnosis presents challenges such as: • Difficult, early and rapid diagnosis in exposed infants because of the persistence of transplacental passage of malernal immunoglobulin G (lgG) HIV antibodies • Timing of HIV transmission from mother to child that affects the sensitivity and specificity of available HIV diagnostic assays • The risk of the infant being exposed to HIV throughout the duration of breast-feeding • The use and role of quantitative and qualitative HIV virological assays • The use and role of the immune complex-dissociated (ICD) p24 antigen detection assay for diagnosis and prognosis • The global existence of multiple c1ades or subtypes of HIV and the impact on assay detection.'·5-," 1. INTRODUcnON DIAGNOSIS OF PERINATAl HIV-l INFECTION IN SOUTH AFRICA lynne M Webber, MMedPath (Viml), DTH Department of Medical Virology, Institute at Pathology, Univmity of Pretorio. Mark Cotton. FCPa,d, MM,d rPaed), DTM&H, DCH rSA) Department of Paediatrics and Child Health, University of Stellenbosch and Tygerberg Children's Hospital, W Cape Wendy Stevens, MB Beh, Mlvfed (Haem) Department of Haematology, University of the Witwatersrand, Johannesburg These guidelines for best practice under both ideal and resource-constrained conditions are intended to provide guidance for health care professionals on the laboratory diagnosis of HIV-l-infected and non-infected infants and young children. Resources, circumstances and decisions will differ across the wide range of clinical settings in South Africa. These guidelines have therefore been formulated recognising the following needs: • Diagnosis of HIV infection in infants and young children born to mothers of unknown HIV serostatus or changing HN serostatus in the perinatal or breast- feeding period • Management of HIV-infected or HIV-exposed infants and children with regard to implementation of prophylaxis for opportunistic infections • Early identification of HIV infected infants critical for clinical management and initiation of antiretroviral therapy • Decisions regarding the continuation or cessation of breast-'eeding practices and the possible implementation of alternative feeding practices • Early diagnosis of HIV infection in infants considered for adoption • Revised and updated guidelines as new data on laboratory techniques and the management of HIV infeclion are acquired:') Rates of HIV in ection among pregnant women are still increasing and rhe perinaral lransmission of HIV in South Africa remains a perlinent and critical issue: (Refer to the guidelines on preventing mother-to-child transmission of HIV-l in South Africa, Southern African Journal of HIV Medicine, Issue 4, May 2001.) The diagnosis of HIV infection among infants should begin with identifying HIV infeclion in women before and during every pregnancy and rhis awareness shoul also identify rhe HI -in'ecred infant:' THE SOUTHER MRICA JOURNAL Of HIV MEDICINE ----------- AUGUST 2001 Diagnosis of perinatally acquired HIV infection. I Breast-fed or mixed I I Non-breast-fed I ~ ~ DNA PCR + DNA PCR- I I DNA PCR + I DNA PCR- I I I• • Confirmatory Stop breast-feeding Confirmatory Repeat DNA PCR DNA PCR+ for 3/12 then repeat DNA PCR + 3 months laterDNAPCR ~ /~ /~ Continue breast- feeding + - + - L ~ ~ Confirmatory Confir- DNA PCR+ matory Not J. DNA infected PCR+ Prophylaxis for opportunistic Repeat /infections DNA PCR Consider for antiretroviral therapy 3 months Prophylaxis for later opportunistic infections Consider for antiretroviral therapy • ! ! Referral for clinical management Referral for clinical management I • In resource-poor settings: (a) serial ELlSA antibody assays may be done at 3-monthly intervals from 6 months of age (b) serum p24 antigen assays (with ICD) may be useful in symptomatic subjects. • Two +Ve DNA PCRs are diagnostic of HIV infection. • An HIV RNA quantitative assay may be used as the second confirmatory test. indicate non-infection [if under 15 months of age, EUSA tests should be at least a month apart). • For infants younger than 12 months yet older than 6 weeks of age, provided breast-feeding has ceased 3 months previously, two negative HIV DNA polymerase chain reaction (peR) test results would indicate non- infeCllOn. be defined as an infant/child who has undergone two negative HIV serological or virological tests; such children can be classified into two distinct age categories: • For children older than 12 months of age, provided breast-feeding has ceased 3 months previously, two negative HIV serological teslS based on the enzyme- linked immunosorbent assay (EUSA) method would AUGUST 200 I ------------ THE SOUTHHtN AFRICAN JOURNAL O~ HIV MEDICINE 3. DEFINITION OF AN HIV-INFECTED INFANT/CHILD AND RECOMMENDATIONS ON THE USE OF HIV TESTS HIV diagnostic techniques are difficult in infants and young children as a result of the persistence of maternal antibodies up to 18 mo'nths of age."" The HIV DNA PCR detecting the DNA proviral form of the integrated virus into the genome of peripheral blood cells, is considered the test of choice for the diagnosis of perinatally acquired HIV infection.') The PCR is a diagnostic qualitative reaction compared with the RNA quantitative reaction (viral load) which is applied in the prognostic staging or clinical monitoring of patients.' The HIV DNA PCR is a rapid and accurate method for identification of HIV infection in infants and young children less than 18 months of age and two tests performed on separate samples are 98.5Ofa accurate in identifying infection status after 28 days of age." However, PCR amplifications can be prone to carry over contamination and testing should take place strictly according to the manufacturer's instructions and only in areas dedicated for PCR work. HIV DNA PCR methods are commercially available and reliable when standardised and performed in laboratories following good laboratory practices. These tests have been accurate for all known HIV-l subtypes but ongoing molecular surveillance is necessary should novel subtypes emerge. Two HIV DNA PCR tests should be performed on infants between 6 weeks and 12 months of age. If the HIV DNA PCR is positive, breast-feeding should continue where applicable and the infant should receive prophylaxis for opportunistic infections, such as Pneumocystis carinii pneumonia (PCP). Reports have indicated that the HIV RNA quantitative detection assays were more sensitive for early detection of HIV infection in infants born to HIV-infected women than the HIV DNA PCR assay. Nonetheless, a quantitative assay should not be used as a diagnostic tool and its clinical applications are clearly related to prognosis and further management of the patient"ln infants with a positive HIV DNA PCR resul~ the quantitative RNA assay may confirm HIV infection and provide additional data relevant to prognosis and as a baseline before antiretroviral therapy." Measurement of HIV p24 antigen in blood is not sensitive enough to be used for early diagnosis of HIV infection in infants and young children, even if immune complex- dissociated methods are used for sample preparation."" However, repeatedly positive HIV p24 antigen tests could be diagnostic of HIV infection and may be utilised in a resource-constrained setting, but use of a single positive result as a sole diagnostic test must be discouraged. The Western blot assay and the CD4 count should not be used for diagnostic purposes. The CD4 count as a diagnostic tool remains unreliable until local reference ranges for infants and young children have been studied and established. 4. RECOMMENDATIONS FOR SPECIAL CIRCUMSTANCES HIV TESTING FOR ABANDONED INFANTS AND INFANTS FOR ADOPTION There is an urgent need to diagnose early HIV infection in abandoned infants, especially those considered for adoption. Often the experience has been that HIV-positive infants remain at the institutions for extended periods before a final diagnosis of infection or non-infection is made. In turn, if these children are already older than 1year it is more difficult to find foster or permanent homes for them. It is therefore recommended that these guidelines on diagnosis of perinatal HIV infection in South Africa be applied in these circumstances. HIV TESTING FOR SEXUALLY ABUSED INFANTS AND YOUNG CHILDREN The management of sexually abused infants and young children is another area of controversy and uncertainty; however, it is recommended that these guidelines be applied in these circumstances." REFERENCES 1. Gray GE. Mclntyre lA, Jivkov B, Violari A Preventing mother-ta-child transmission of HIV-l in South Africa; recommendations for best prae:tiet=. Southun African Journal ofHN Medicine 2001; 4: 15-26. 2 Nielsen K, Bryson YJ. HIV/AIDS in infants, children and adolescents. Pediatt Oin NorthAm 2000; 47 (l): 39-58. 3. Bertolli J, St Louis ME, Simonds RJ, etal. Estimating the timing of mother-to- child transmission of human immunodenciency virus in a breast-feeding population in Kinshasa. lfnfectDis 1996; 174: 722-726. 4. Davis5F, Byers RHjun,lindegren ML CafdwelJ B. Karon JM, Gwinn M. 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