Currently, clinical and laboratory tests have been developed for diagnostics in newborns and children of the first year of life.
- A child who has had contact with an HIV-infected mother in the perinatal period can be diagnosed with HIV infection only if the results of virological tests for HIV are positive twice. In this case, the results of the study of umbilical cord blood are not taken into account, since the contamination of the test sample with maternal blood is possible. Positive results of double isolation of the HIV strain by virological examination of peripheral blood monocytes or positive results of PCR for DNA or RNA in combination with a single isolation of the HIV strain from monocytes are considered reliable. These two studies are performed at regular intervals, and the baby should not receive breast milk from an HIV-infected mother.
- A child born to an HIV-infected mother is considered not infected with HIV if the above studies consistently give negative results, and the child must be at least 4 months old and should not receive breast milk from an HIV-infected mother.
- In a child born to an HIV-infected mother, serologic tests for HIV can remain positive for up to 18 months due to persistent maternal antibodies that are transmitted transplacentally. After reaching the age of 18 months, seropositivity persists only in HIV - infected children; while antibodies to HIV-1 can be detected using enzyme-linked immunosorbent assay (ELISA), immunofluorescence (RIF), immune blotting (IV).
- If a child, in the absence of agammaglobulinemia, has negative serological reactions upon reaching 12 months of age, such a child is considered not infected with HIV.
Thus, a child under 18 months. is considered infected if he has HIV culture, positive PCR, or HIV antigen detected in two or more tests. A child born to an HIV-infected mother is considered uninfected if two or more negative tests for HIV antibodies in ELISA are obtained at the age of 6 to 18 months. Or one negative result over 18 months. and there are no other HIV positive laboratory tests and no AIDS indicator diseases.
Laboratory tests and their interpretation, according to different authors, are given below in table.
Polymerase chain reaction (PCR) allows detecting genomic (proviral) DNA sequences in a polyacrylamide gel using radioactively labeled enzyme probes. PCR is highly sensitive, it allows you to detect HIV DNA in 6 months. before the appearance of antibodies. However, due to false positive results, PCR standardization and the introduction of a fully automated reaction setup are required [Rakhmanova AG, 1996].
In newborns, to distinguish maternal antibodies from those caused by HIV infection, HIV-specific IgA and IgM, which do not pass through the placenta, are determined in the blood serum.
Anti-HIV antibodies of the IgM class can appear in an infected child at 2 to 3 months of age, but their production with an immature immune system is not natural. In this regard, the absence of antibodies of the IgM class does not yet allow making a conclusion about the child's HIV infection. On the contrary, the detection of antibodies of the IgA class is a highly sensitive and specific method for diagnosing perinatal HIV infection in children over three and especially six months of age.
In the first months of life in children, a deficiency of B-cell immunity is revealed, which is manifested by a violation of the production of antibodies to bacteria and a decrease in resistance to bacterial infections against the background of severe hypergammaglobulinemia.
With early transplacental infection, the virus is not recognized by the immature immune system and antibodies to HIV are not produced in children.
Nevertheless, in any case, the final diagnosis of HIV infection in a child who was born to an HIV-positive mother in most cases (due to the lack of modern laboratory diagnostics in many hospitals) is established only when the detection of anti-HIV antibodies continues more than 18 months after birth. Due to the possible delay in the appearance in some of these children of their own anti-HIV antibodies, standard serological tests are repeated every 3-6 months until the age of three years (if possible, using the results of HIV culture isolation).
Analyzing various diagnostic criteria for the diagnosis of HIV infection, P. Palumbo and B. Sandra (1998) note that virological tests are of greater value for HIV infection in newborns and children than serological ones. The results of PCR or detection of the culture of the virus in the peripheral blood are the most reasoned for the diagnosis of HIV infection.
The p24 antigen can be detected, but this is less specific. However, each positive diagnostic test requires re-determination, as false positive results are possible.
For example, a decrease in body weight, preterm labor, microcephaly, and dysrania may indicate transplacental infection in newborns.
Other signs of congenital HIV infection are also distinguished - craniofacial dysmorphism (hypertaylorism, wide protruding forehead, sinking nasal bridge, protruding groove of the upper lip), retardation in psychomotor development, recurrent diarrhea, the presence of blue sclera, progressive neurological symptoms (loss of intelligence , motor disorders, pathological reflexes, paresis). The latter is observed in 10-30% of HIV-infected children, and is usually detected at the age of 6 months.
However, clinical criteria are not always acceptable for children in the first months of life. Of great importance are various risk factors for birth, for example, drug addiction in parents, their bisexuality, hemophilia of their sexual partners [Rakhmanova A. G., 1996].
In addition, in such children, in the presence of neurological symptoms, it is necessary to exclude toxoplasmosis, cytomegalovirus and herpes infections, brain lymphoma, measles and other viral encephalitis, the consequences of birth trauma, and only then associate the CNS pathology with HIV infection.
The disease leads to damage to the immune systemthe child, its significant weakening, all kinds of failures in the work of the immune system.
The disease has a progressive course, and if no measures are taken, leads to the death of the patient. HIV - infection contributes to the development of a number of other infectious diseases, the emergence of oncological tumors.
The mode of infection, characteristic signs, symptoms and methods of HIV treatment in children is different than in adults, therefore, parents whose child has HIV should receive full information on time about the features of the disease in children.
What is provoking?
There are several reasons for a child to become infected with HIV. You can get infected in several ways:
- promiscuous sex life a teenager, unprotected sex with a partner who is a carrier of the infection, taking drugs when injection is carried out through a shared syringe;
- intrauterine infection fetus through the placenta, infection during childbirth and breastfeeding;
- during blood transfusion and its components, if the donor has an appropriate diagnosis;
- using medical equipment (syringes, gynecological, surgical supplies) that has not undergone special processing;
- during the procedure organ transplant from an infected donor.
It is known that the virus - the causative agent of infection is transmitted through blood, semen, vaginal microflora.
The virus is also found in the saliva and urine of the patient, however, its content in these substances is too small to infect others.
Symptoms
How does HIV manifest in children? Symptoms and signs of HIV infection in children at different stages of the disease may be different:
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About symptoms You can learn HIV infection from the video:
How is it confirmed?
What is diagnostics? In order to make an accurate diagnosis, the doctor evaluates the clinical manifestations of the disease, as well as the data of the following laboratory tests:
Principles and approaches to treatment
Unfortunately, the use of special therapy does not completely eliminate the virus, and, accordingly, cure the child.
The use of such funds can only suppress the multiplication of the virus (replication), temporarily normalize the patient's condition.
Completely destroy the cells of the virus, alas, does not seem possible... In order to help the patient, special principles and rules of treatment are applied:
Criteria for prescribing HAART
Specific antiretroviral therapy (HAART) is prescribed when indicated.
However, it is important to remember that children of the first year of life are prescribed HAART on a mandatory basis (if diagnosed with HIV), without special indications.
At an older age, HAART is used if:
- the number of immune cells (CD4) that determine the child's immune status, reduced to 15% or less;
- cD4 count is about 15-20%, but the patient has serious secondary bacterial diseases.
Antiretroviral therapy
HAART - main therapyused in the treatment of HIV infection.
To achieve a positive result, a combination of several antiviral drugs is used.
Monotherapy(use of one agent) is possible only for prophylactic purposes, when a child born to an infected mother has an undefined (or negative) HIV status.
A large number of antiretroviral drugswith a high degree of efficiency. The most commonly used combinations of funds such as:
- Lamivudine;
- Didanosine;
- Videx;
- Zidovudine;
- Abacavir;
- Ziagen;
- Olitid;
- Retrovir.
Prevention in the perinatal period
A woman who is HIV-positive may well give birth to a healthy baby.
To do this, first of all, you need to carefully monitor your own health (timely identify the presence of HIV infection, timely contact the AIDS center), and also observe a number of preventive measures, minimizing the risk of intrauterine infection fetus.
This requires:
- No later than 14 weeks of pregnancy, undergo a special chemotherapycarried out at the AIDS Center.
- During childbirth, a woman is injected with special antiretroviral drugs... The newborn baby also receives appropriate treatment as a preventive measure.
- After a preventive course of therapy, the child is taken blood test, since the effect of the drug can provoke the development of anemia, neutrophilia. Indicators of hemoglobin level and the number of neutrophils, as a rule, normalize on their own within a few days.
Unfortunately, it is impossible to completely cure HIV infection. However, a timely appeal to a specialized medical center, well-chosen therapy, proper child care, allow you to achieve a positive result, improve the quality of life of the little patient.
How does chickenpox manifest in children? you will find on our website.
Dr. Komarovsky will tell about the ways of HIV transmission to children in this video:
We kindly ask you not to self-medicate. Make an appointment with a doctor!
The diagnosis of HIV infection is excluded or established in children with perinatal transmission using serological and virological methods. Serological tests are aimed at detecting antibodies to the virus in blood serum by ELISA and immunoblot. Virological methods (virus isolation, PCR, viral load) make it possible to identify the virus and / or its components - proteins and nucleic acids, in particular, gp24-aHTHreH, which is present in the composition of viral particles in significant quantities. Rapid and early serological diagnosis of HIV infection in children is difficult, since IgG antibodies are transmitted from the mother transplacentally and are present in children under 18 months of age. Distinguishing between maternal and own antibodies to HIV is not possible. In uninfected children, maternal antibodies usually disappear by 9-12 months, this, with a negative PCR, suggests that the child has not been infected. The results of a serological examination of newborns are taken into account in the final diagnosis at any age. However, in some cases, antibodies may not be detected in HIV-positive children. This is due to congenital hypogammaglobulinemia, in which, during the period when maternal antibodies have already disappeared (6-18 months), their antibodies to HIV antigens do not develop in titers sufficient for detection in ELISA. Thus, a negative serological test at an early age is insufficient to conclude that there is no infection.
To establish or completely deny HIV infection in newborns and children of the first year of life, viral tests are recommended.
The most reliable methods are polymerase chain reaction (PCR) (DNA and RNA test) and cultural and virological. Their use makes it possible to establish a diagnosis in 30-50% of HIV-infected children immediately after birth and in almost 100% at the age of 3-6 months. The PCR method is based on the detection of viral nucleic acids - free RNA or proviral DNA in blood lymphocytes, the presence which indicates the multiplication of HIV in the child's body. Both types of tests can be used to diagnose HIV infection in children: it has been shown that they do not differ in sensitivity, but the DNA test is much easier to perform and cheaper. An important condition for obtaining reliable results is the use of only the child's venous blood for analysis. The PCR method is highly sensitive: a few copies of DNA or RNA in a plasma sample may be enough for a test result to be positive. Therefore, cord blood is not suitable for molecular testing. This is due to the possibility of contamination of the baby's blood with maternal blood during childbirth; the slightest admixture of viral particles or lymphocytes of an HIV-infected mother can lead to a false positive result of the LCR analysis, which will complicate the establishment of the correct diagnosis for the child.
According to experts, diagnostic PCR testing should be carried out three times in the following terms: - from birth to 48 hours of life; at the age of 1-2 months; -4-6 months Most experts agree that when infected in uteri, a positive result of virological examination is observed in the first 48 hours of life. As the child's age increases, so does the detectability of HIV DNA during DNA testing. In the case of perinatal infection, only 24% of infected children are detected in the first 7 days, but after a week their share is 93%. Therefore, most infected children can be diagnosed with HIV infection at the age of 1 month. with repeated PCR analysis.
Children who have negative virological test results at birth and at the age of 1 month are examined at the age of 4-6 months. By the age of 4-6 months, practically all HIV-infected children show positive results of the PCR test.
Another test for assessing virological status and monitoring infection is to determine the viral load - the concentration of the virus, expressed in the number of copies of HIV RNA (proportional to the number of viral particles) per 1 ml of plasma. Children have a high viral load that can persist in a child's body for a long time. It has been shown that during intrauterine infection at the time of birth, the concentration of the virus is relatively low (<10 000 копий/мл), однако в течение первых 2 месяцев жизни резко возрастает (100 000 — 1 000 000 копий РНК/ мл и более) и затем снижается очень медленно в течение нескольких лет. Высокий уровень вирусной нагрузки (более 105/мл в возрасте 1-2 мес. обычно соответствует быстрому прогрессированию ВИЧ-инфекции. Для детей характерны более выраженные биологические колебания концентрации вируса в крови, поэтому в возрасте до 2 лет существенными следует считать не менее чем пятикратные различия показателей (для взрослых — 3-кратные). В результате проведенных исследований в США выявлена зависимость уровня РНК ВИЧ и показателей смертности от пола ребенка. Отмечено, что для мальчиков характерен более высокий уровень РНК ВИЧ, но не смотря на это, выживаемость мальчиков существенно выше выживаемости девочек. Показатели вирусной нагрузки имеют значение для оценки состояния, прогноза и решения вопроса о назначении и эффективности антиретровирусной терапии. При хорошем результате лечения уровень нагрузки падает в 100-1000 раз и может оказаться ниже порога чувствительности тест - системы (так называемый «неопределяемый уровень»).
Thus, in children aged 6 to 18 months. only a combination of two methods - serological and virological - can confirm or reject HIV infection. It is possible to conclude that it is absent in children without clinical signs of HIV infection with two negative results of serological and virological tests. With a combination of positive virological and serological results, infection is confirmed. After 18 months the only confirmation of HIV infection can be the determination of antibodies to HIV in the child's serum: after this period they can be detected there only if they are produced by their own immune system in response to contact with the virus.
Timely diagnostics of HIV infection in a child is not only a real chance to significantly improve the prognosis of the disease, but also an opportunity to significantly improve the quality of life of a child, to create optimal conditions for its development.
HIV diagnosis in children
HIV in children can be detected:
- at the prenatal stage;
- after birth.
Antenatal fetal diagnostics is one of the most urgent and actively developing areas of diagnostics. At this stage, HIV can be detected during the following diagnostic activities:
- amniocentesis;
- chorionic villus sampling biopsy.
The main disadvantage of these research methods is the existing risk of a negative effect of the procedure on the condition of the mother and fetus.
Postnatal HIV diagnosis is reduced to the detection of antibodies to the pathogen in the baby's blood, as well as a section of viral genetic material.
Indications for this laboratory study may be:
- the presence of risk factors for infection in the mother;
- One of the parents is HIV positive;
- fetal and embryopathy.
Diagnostic features
For the formation of antiviral antibodies, at least two weeks must pass from the moment of infection. In some clinical situations, antibodies to the virus are detected in the child's blood even after nine months.
The principles for diagnosing HIV can also differ. Testing methods depend on the diagnostic protocols that are approved in a particular country in the world. In the blood, antibodies can be detected both to the internal and to the surface antigen of the viral particle.
Serological methods used in laboratories can be roughly divided into:
- screening;
- specific.
It should be noted that the presence of maternal antibodies complicates the diagnosis of HIV in babies of the first year of life. The most important features of the diagnosis of this infection in them, given the immaturity of their own immune mechanisms, include:
- the formation of its own immune response in 30-60% of cases after a year and a half after intrauterine infection;
- the presence of antibodies to the pathogen, even at the stage of a detailed clinical picture of AIDS.
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HIV infection is not transmitted to most children born to HIV-positive mothers
Risk of mother-to-child transmission of HIV
20% during pregnancy.
60% - during childbirth.
20% - with breastfeeding.
What is required for an HIV-infected woman to give birth to a healthy baby?
Prevention of vertical transmission (HTP) is a set of measures aimed at preventing HIV transmission from mother to child at all possible stages (pregnancy, childbirth, feeding).
Algorithm of preventive measures:
- If a pregnant woman is diagnosed with HIV infection, she needs to register with a gynecologist at the AIDS Center.
- From 24-28 weeks of pregnancy, an HIV-positive pregnant woman should start taking antiviral drugs (according to the approved protocol) until the time of delivery. The drugs will be given to her at the regional AIDS center free of charge.
- The method of delivery is selected together with the gynecologist at the AIDS Center individually, according to the approved protocol, depending on the viral load (the amount of virus in the woman's blood).
- If prophylactic ART is started late (during labor) or viral load is high, delivery by caesarean section is recommended to avoid contact of the baby with the mother's blood and vaginal secretions as much as possible.
- Immediately after birth, each child born to an HIV-positive mother is prescribed the antiviral drug Zidovudine in syrup for 7 or 28 days. The drug is given at the maternity hospital for the entire course of admission.
- Breastfeeding is not recommended. Immediately after birth, the child is transferred to artificial feeding with adapted milk formulas.
With all the above measures, the risk of HIV transmission from mother to child is no more than 1-2%.
Risk factors for mother-to-child transmission of HIV
- Stage of mother's HIV infection.
- Lack of preventive treatment during pregnancy.
- Multiple pregnancy.
- Long dry period.
- Premature birth.
- Self-delivery.
- Bleeding, aspiration during labor.
- Breast-feeding.
- Injecting drug use, alcohol abuse during pregnancy.
- Coinfection (tuberculosis, hepatitis).
- Extragenital pathology.
Features of the management of a child born of an HIV-positive mother in the pediatric area
- Study your discharge from the maternity hospital carefully.
- Pay attention to: child's vaccination (vaccination against hepatitis B - carried out, BCG has not been carried out); Zidovudine prophylactic regimen (7 or 28 days).
- Check the presence of Zidovudine syrup in the mother and whether she knows about the regimen and duration of taking the drug (2 times a day at the rate of 4 mg / kg for each dose, for 7 or 28 days). Explain to your mother again why you need to take it (prevention of HIV infection in a newborn).
- All children, until the HIV status is clarified, are under the supervision of a pediatrician of the AIDS center, a district pediatrician and a pediatric phthisiatrician.
- The child is examined and treated for all concomitant diseases, at the place of residence, on a general basis.
- The child's medical records should be kept separately out of the reach of others and remember that information about the status of the child and his parents is strictly confidential.
- After the child is removed from the register for HIV infection, it is recommended to replace his outpatient card with a new one, which will lack information that the child was registered at the AIDS center.
Criteria for registration and deregistration at the AIDS Center
For the first examination and examination of the child, it is necessary to get a referral to the regional AIDS center at the age of 1 month, where he will be taken blood for the determination of HIV RNA by PCR and for the determination of antibodies to HIV by ELISA. Further tactics of child management depends on the results of the study.
Screening for the determination of PCR RNA HIV in 1 month
| Negative PCR result | Positive PCR result |
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The main clinical symptoms of HIV infection in children
- Delayed weight gain and height. Anthropometry is mandatory monthly.
- Delay in psychomotor and physical development. Compulsory supervision of a neurologist.
- Painless enlargement of lymph nodes (over 0.5 cm) in two or more groups (cervical, axillary, etc.)
- Enlargement of the liver and spleen for no apparent reason.
- Recurrent parotitis (enlarged salivary glands).
- Relapses of thrush or manifestations of thrush in children over 6 months of age.
- Candidiasis of the skin and mucous membranes.
- Recurrent bacterial infections: pneumonia, otitis media, sinusitis, pyoderma, etc.
- Relapses of herpes simplex and herpes zoster.
- Chickenpox relapses.
- Common molluscum contagiosum.
- Angular cheilitis, "seizures".
Features of observation, nutrition and vaccination of HIV-positive children
- All HIV-positive children are registered with the pediatrician of the AIDS center, the district pediatrician, and the pediatric phthisiatrician.
- An HIV-positive child is examined by a pediatrician of the AIDS center and a district pediatrician at least once every 3 months.
- At the reception at the AIDS Center, anthropometry, examination by a pediatrician, assessment of the state of immunity (blood sampling to determine the number of CD4 lymphocytes), determination of viral load are performed.
- Vaccination of HIV-positive children is carried out in the polyclinic at the place of residence in accordance with Order No. 48 of 03.02.06 and Order No. 206 of 07.04.06.
- It is recommended that HIV-positive children increase their caloric intake by an average of 30% of the age norm.
- At the pediatric site at the place of residence, the mandatory examination of an HIV-positive child includes:
- Anthropometry (up to 6 months - 1 time per month), after 6 months 1 time per 3 months.
- Examination of a phthisiatrician once every 6 months.
- Mantoux reaction once every 6 months.
- Examination by an ophthalmologist with a description of the fundus once every 12 months.
- UAC, OAM, biochemical blood test, blood sugar - once every 6 months.
IMPORTANT: HIV-positive children attend kindergartens and schools on a common basis. With parental consent, only the medical staff of a child care institution or school can be informed about the HIV status of a child.
IMPORTANT: HIV-positive children undergo annual health improvement in children's health institutions of the appropriate profile.
Principles and approaches to treating HIV infection in children
- Highly active antiretroviral therapy (HAART) is used to treat HIV infection - a combination of several antiretroviral drugs that are prescribed simultaneously, continuously and for life.
- The appointment of HAART to an HIV-infected child is carried out on a commission by the specialists of the AIDS Center. with the written consent of the parents (guardians).
- Drugs for the treatment of HIV infection are handed out to the child's parents when they visit the AIDS center with recommendations for admission and doses.
- HAART suppresses the multiplication of the virus, but does not completely remove it from the body.
- The use of monotherapy (one ARV drug) or biterapy (two ARV drugs) is not permissible, as it leads to the formation of HIV resistance to ARV drugs and ineffectiveness of further treatment.
- It is important to strictly adhere to the regimen of taking drugs (dose, time, frequency of receptions) - violation of the treatment regimen can quickly lead to its ineffectiveness.
- If inpatient treatment is required, an HIV-infected child can be hospitalized in a specialized department or in any health facility (according to indications).