MODULE 2: DIAGNOSIS AND

STAGING OF PAEDIATRIC
HIV

Kenya National “Comprehensive

Paediatric HIV Care Course”.
NASCOP/UoN/ MU/KNH/GGCH
 Diagnosis and Staging of
Paediatric HIV-Scope
Unit I: Clinical presentation of Paediatric HIV
Unit II: Diagnosis:
 Clinical diagnosis
 Laboratory diagnosis
Unit III: Staging:
 Clinical staging
 Immunological staging.

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
2
 UNIT 1:
Clinical Presentation of
HIV in children

Kenya National “Comprehensive

Paediatric HIV Care Course”.
 Unit I: Clinical Presentation of
HIV in Children
By the end of this session, the participant should
be able to:

 Describe common clinical presentations of

Paediatric HIV infection.

 Compare between common Paediatric

conditions and clinical signs of paediatric HIV.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
4
 Clinical Suspicion Of HIV

 All children presenting to healthcare

facilities should be assessed with HIV
diagnosis in mind.

 Certain clinical conditions, if present, point

to high probability of HIV infection in a
child
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
5
Clinical Signs & Conditions Suggestive
Of HIV Infection in a Child
 Recurrent severe bacterial infection
 Persistent or recurrent oral thrush
 Parotid enlargement
 Generalized lymphadenopathy
 Hepatosplenomegaly (non-malaria areas)
 Persistent or recurrent fever
 Neurologic dysfunction
 Persistent generalized dermatitis
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
6
 Clinical Signs & Conditions Suggestive
Of HIV Infection in a Child
 Oesophageal candidiasis (thrush)
 Herpes zoster (shingles)
 Invasive salmonella infection
 Pneumocystis jiroveci pneumonia (PCP)
 Extrapulmonary Cryptococcus
 Lymphoma
 Kaposi’s sarcoma
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
7
 Clinical Signs & Conditions Common
in Both HIV positive and negative
Children

 Otitis media - persistent or recurrent

 Diarrhoea – persistent or recurrent
 Severe pneumonia
 Tuberculosis
 Failure to thrive

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
8
 Asymptomatic HIV infection
 Most (80%) HIV infected children will be
symptomatic by the end of the first year.
 A small number may remain asymptomatic
for a long time. They are referred to as
slow progressers or non-progressers.
 It is therefore important establish HIV
status of all children.

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
9
 UNIT II:
Diagnosis of HIV in
Children

CLINICAL AND LABORATORY

DIAGNOSIS
 Unit II: Diagnosis of HIV in
Children
By the end of this session, the participant should be
able to:
 Discuss entry points for HIV diagnosis in children,
and the importance of confirming diagnosis of
paediatric HIV .
 Make a clinical diagnosis of HIV/AIDS using the
integrated management of childhood illness (IMCI)
tool.
 Carry out laboratory diagnosis using HIV antibody
tests and virologic tests
 Interpret the results of laboratory diagnostic tests in
children under and over 18 months
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
11
 Entry Points for HIV Diagnosis
HIV exposed and/or infected children can be identified by
actively seeking to test them in health services where they
or their parents seek care.
 Sick children services (in-patient & out-patient)

 PMTCT clinics

 MCH clinics

 TB clinics & Adult HIV clinics

 Home-based testing

HIV positive parents should be encouraged to bring all

their children in for testing
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
12
 Significance of diagnosis.
 Confirmation of a diagnosis of HIV
infection provides an entry point for
appropriate care for the child and the
family.

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
13
 Clinical Diagnosis for HIV

 Using Integrated management of

childhood illness (IMCI) tool one
can easily identify children highly
likely to have HIV infection

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
14
 IMCI definition of symptomatic
HIV infection
Presence of 3 or more of the following:
 TB in any parent in the last 5 years.
 Pneumonia (now or previously).
 2 or more episodes of persistent diarrhoea (>14
days).
 Growth faltering or weight < 3rd centile
(below “very low weight curve” in card.
 Enlarged lymph nodes in 2 or more of the following
sites -neck, axilla, groin.
 Oral thrush.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
15
 Laboratory Diagnosis
There are two types of laboratory tests for HIV
diagnosis:

Antibody tests – detect antibody to HIV.

Virologic tests – detect HIV virus or antigen.

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
16
 Laboratory Diagnosis
1. Antibody tests – detect antibodies
to HIV proteins in blood
 HIV ELISA (EIA)
 Rapid tests: done at the point of care on drops
of blood. Examples are Unigold, Determine and
Bioline.

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
17
 Determine Assay
Apply 50L sample (Whole blood, Serum, Plasma)

PATIENT

Add 1 drop of Chase Buffer (Whole blood)

Allow to develop (15 min)

Interpret results
Module 2: Pediatric HIV, 18
Diagnosis and Staging,
Determine: Interpretation of Results
POSITIVE NEGATIVE INVALID INVALID
472U100 472U100 472U100 472U100

HIV-1/2 HIV-1/2 HIV-1/2 HIV-1/2

7A 7A 7A 7A
CONTROL

CONTROL

CONTROL

CONTROL
PATIENT

PATIENT
PATIENT

PATIENT

Module 2: Pediatric HIV, 19

Diagnosis and Staging,
 Unigold Assay
Add 2 drops of Sample (Whole blood, Serum, Plasma)

Add 2 drops of Wash Reagent

Allow to develop (10 min)

Interpret results
Module 2: Pediatric HIV, 20
Diagnosis and Staging,
 ` of Results
Unigold:Interpretation

POSITIVE NEGATIVE INVALID INVALID

Module 2: Pediatric HIV, 21

Diagnosis and Staging,
 Laboratory Diagnosis in Children
above 18 months

Child > 18 months

 A positive HIV antibody test confirms

HIV infection
 A negative HIV antibody test rules out

HIV infection (beware of window period)

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
22
 Laboratory Diagnosis
Antibody Test
Child < 18 months: a positive antibody test below 18
months may be from
 Maternal HIV antibodies passively transferred to

infant
 Infant generated HIV antibodies if infant is HIV

infected.
 maternal antibodies may persist in her infant up to 18 months
 HIV antibody tests are positive in ALL children born to HIV
infected women.
Positive HIV antibody test at this age are
therefore not diagnostic, but only shows child
has been HIV exposed.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
23
 Early Infant Diagnosis (EID)
 Determine mother’s status by HIV rapid
test
 If mother’s HIV status is not known, do
HIV rapid test on infant at 6 weeks
 Positive antibody test in infant (HIV
exposed infant): do HIV DNA PCR test at
same sitting.
dule 2: Pediatric
 Start on cotrimoxazole prophylaxis
, Diagnosis and
Staging,
24
March 2011
 Early Infant Diagnosis
HIV exposed infant: HIV antibody test negative
at age 6 weeks (or at first contact) AND
breastfeeding
 Repeat HIV rapid test at 9, 12 and 18months

 If negative – child is HIV free

 If positive – do confirmatory HIV PCR

 For all HIV positive infants – confirm infection

by antibody test at 18months.

dule 2: Pediatric
, Diagnosis and
Staging,
25
March 2011
 Laboratory Diagnosis:
Virologic Tests
Virologic tests – detect HIV virus in
blood.
 Confirms HIV diagnosis in children under

18 months
 Various types:

- DNA PCR (can be done on dried blood spots)

- RNA PCR (performed on whole blood)
- P24 antigen (immune-complex dissociated)
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
26
 Dried Blood Spot (DBS)
Dried blood spot is:
 Whole blood dried on filter paper

 Usually obtained from pricking skin, not

from phlebotomy
 Requires only a small amount of blood

 Easy to store

 Easy to transport
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
27
 Procedure for DBS collection
2nd choice

1. Warm the area to be tested

2. Put on gloves, wash hands
3. Position baby with foot down
4. Clean area, dry 30 sec
5. Press lancet into foot, prick
skin
6. Wipe away first drop
7. Allow large drop to collect
8. Touch blood drop to card
9. Fill entire circle with drop
10. Fill at least 2 circles
11. Clean foot, no bandage Module 2: Pediatric HIV,
Diagnosis and Staging,
1st choice
March 2011
28
 Fill at least 2 circles

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
29
 How to Dry DBS
 Don’t touch or smear the blood spots
 Allow the specimen to air dry horizontally
(flat) for at least 3 hours
 Keep away from direct sunlight, dust,
and bugs
 Do not heat, stack or allow DBS to touch
anything during the drying process
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
30
 Insert Into Sealable Plastic
Bag

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
31
TIMING AND RATES OF MTCT

30% become infected

through MTCT

5% intrauterine
PCR +ve first week life

15% during delivery

PCR +ve by age 1 month

10% via breastfeeding

Do PCR 1 month after stop bf

Module 2: Pediatric HIV, 32

Diagnosis and Staging,
 When to do PCR For Diagnosis of HIV
exposed Child of < 18 Months
If NOT breastfeeding:
 Do PCR from age 6 weeks

 (final confirmatory antibody test advisable at 18

months)

If breastfeeding:
 Do PCR from age 6 weeks or at first contact
thereafter
 if PCR positive at encourage mother to continue
breastfeeding
 Any HEI who gets a positive PCR at any point will be
initiated on ARVs immediately as a confirmatory test is done
together with a baseline viral load.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
33
 Interpretation of
Laboratory Diagnosis:

Diagnostic Gold standard – is to perform two tests to

confirm or rule out HIV infection
 2 positive virological tests performed on blood

samples taken on 2 separate dates confirms HIV

infection.
 2 or more negative virological tests at age >1 month, one

of which is performed at age > 4 months in a non-

breastfed infant rules out HIV infection.
 Remember, if breastfeeding, wait for 6 or more weeks

after cessation of breastfeeding to do final HIV test.

Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
34
 Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
35
 UNIT III
Staging:

Clinical and immunological

Staging.
 Unit III: Staging: Clinical and
Immunological
By the end of this session, the participant
should be able to:
 Describe clinical staging of HIV in

children
 Describe immunological staging of HIV

in children

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
37
 Clinical Staging
TWO international clinical staging
systems:
 World Health Organisation (WHO)

 Four stages – 1, 2, 3, 4
 Centres for Disease Control (CDC)
 Four stages – N, A, B, C
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
38
 Clinical Staging
Stage WHO CDC

Asymptomatic 1 N

Mild 2 A

Moderate 3 B

Severe (AIDS) 4 C
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
39
WHO Clinical stage:1

 Asymptomatic
 Persistent generalized
lymphadenopathy (PGL)

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
40
 WHO Clinical Stage 2
(Mild clinical conditions)
 Papular pruritic eruptions
 Seborrheic dermatitis
 Fungal nail infections
 Angular cheilitis
 Linear gingival erythema
 Extensive wart and/or molluscum infection (>5% of body
area/face)
 Recurrent oral ulcerations (>2 episodes/g mos)
 Parotid enlargement
 Herpes zoster (>1 episode/12 mos)
 Hepatosplenomegaly
 Recurrent or chronic upper respiratory infection (URI): otitis
media, tonsillitis, otorrhea, sinusitis (>2 episodes/6 mos)
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
41
 WHO Clinical Stage 3
(moderately severe conditions)
 Unexplained moderate malnutrition (-2SD or Z score) not
responding to standard therapy
 Unexplained persistent diarrhea (>14 days)
 Unexplained persistent fever (intermittent or constant, >
1mo)
 Oral candidiasis (outside first 6-8 wks)
 Oral hairy leukoplakia
 Pulmonary tuberculosis, TB lymphadenitis
 Severe recurrent presumed bacterial pneumonia

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
42
 WHO Clinical 3 (Contd)
 Acute necrotizing ulcerative gingivitis/periodontitis
 Lymphoid interstitial pneumonitis (LIP)
 Chronic lung disease incl bronchiectasis
 Unexplained anemia (<8g/dl), neutropenia (<500/mm3), or
thrombocytopenia (<50,000/mm3) for >1 mo.
 HIV-related cardiomyopathy
 HIV-related nephropathy

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
43
 WHO Stage 4 (all ages)
Conditions which can be diagnosed using clinical signs or simple
investigations:
 Unexplained severe wasting/stunting or severe malnutrition not
adequately responding to standard therapy
 Pneumocystis pneumonia
 Recurrent severe presumed bacterial infections (e.g. empyema,
pyomyositis, bone or joint infection, meningitis, but excluding
pneumonia )
 Chronic Herpes simplex infection (of more 1 month duration)
 Extrapulmonary tuberculosis
 Oesophageal Candida
 CNS Toxoplasmosis
 HIV encephalopathy
 Kaposi's sarcoma
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
44
 WHO Stage 4 (all ages – continued)
Conditions where confirmatory diagnostic testing is necessary:
 CMV infection (CMV retinitis or infection of organ other than
liver, spleen, or lymph nodes onset at age 1 month or more)
 Extrapulmonary cryptococcosis (incl meningitis)
 Any disseminated endemic mycosis (e.g. extra-pulmonary
Histoplasmosis, Coccidiomycosis, Penicilliosis)
 Cryptosporidiosis
 Isosporiasis
 Disseminated non-tuberculosis mycobacteria infection
 Candida of trachea, bronchi or lungs
 Acquired HIV related fistula
 Non-Hodgkin's lymphoma
 Progressive multifocal leucoencephalopathy
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
45
 WHO Presumptive Clinical
Stage 4 (age < 18 mths)
 For a symptomatic HIV-antibody positive infant age <18 mths,
make a presumptive diagnosis of severe HIV disease (clinical
stage 4) when*:
a) Two or more of the following are present:
 Oral candidiasis/thrush
 Severe pneumonia
 Severe Sepsis
OR
b) Diagnosis of any AIDS-indicator condition(s) can be made (see
full stage 4 list)

Other supporting evidence: recent HIV-related maternal death or

advanced HIV disease in the mother; and/or CD4 <20%
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
46
 Presumptive stage 4 diagnosis
 Presumptive diagnosis of Stage 4
disease in HIV-antibody positive infants
< 18 mths requires confirmation with
virologic tests when possible, or by
antibody tests after age 18 months.
 It is recommended to be used for ART
decision making in situations where
virological tests are not available
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
47
 Exercise on Clinical Staging
Case 1:
 Toto is 4 yrs old, presents with oral

thrush, recurrent pneumonia, fever for

2 weeks, and weighs 14kg.

 Qtn: What is Toto’s WHO clinical

stage?
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
48
 Exercise on Clinical Staging

ANSWER: WHO stage 3 based on the oral

thrush and recurrent pneumonia

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
49
Exercise on Clinical Staging
Case 2:
 Abba is 10 months and presents with severe
oral thrush and severe sepsis requiring one
month hospitalization. She recently lost her
mother. There is no PCR available for
virologic diagnosis but her HIV antibody test
is positive.

 Qtn: What is her WHO clinical stage?

Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
50
 Exercise on Clinical Staging

Answer: We make a presumptive HIV stage 4

clinical diagnosis in this child based on:
 her positive HIV ELISA
 age less than 18 months
 oral thrush severe sepsis
 and recent death of her mother

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
51
 Immunological Staging
Differences in CD4 counts between
healthy adults and healthy children

 CD4 counts are high in healthy young

children.
 Decline to adult levels by 6 yrs.
 CD4% does NOT change with age.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
52
 NASCOP 2007 – classification of severe
immunosuppression in children

 WHO proposed immune staging 2006 more

complex than previous immune staging
 To maintain simplicity and continuity
NASCOP opted to retain three age-group
classification (< 18 months, 18months –
5 years and above 5 years) when making
ART decisions for ART initiation in children
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
53
WHO Immunological Staging 2006
Classification Age-related CD4 values
immune
deficiency <11 months 12-35 36-59 ≥5 yrs
(%) months (%) months (%) (cells/mm3)

Not Significant >35% >30% >25% >500

Mild 30-35% 25-30% 22-25% 350-499

Advanced 25-30% 20-25% 15-20% 200 - 349

Severe <25% <20% <15% <200 or

Module 2: Pediatric HIV, <15%
Diagnosis and Staging,
March 2011
54
 WHO Indicators of Severe
Immunosuppresion 2006
Severe immuno- < 12 months 12 – 35 36 – 59 5 yr +
suppression months months

By CD4 % < 25% < 20% < 15% < 15%

By CD4 count < 1500 < 750 < 350 < 200

By total < 4000 < 3000 < 2500 < 2000

lymphocyte count
(TLC) per mm3

dule 2: Pediatric
, Diagnosis and
Staging, 55
March 2011
 NASCOP (Kenya) 2010 Criteria for
initiating ART in children
Age in months ≤24 mth 25–59 mth 5 yr +

By CD4 % ALL < 25% < 20%

By CD4 count ALL < 1000 < 500

By WHO ALL 3 or 4 3 or 4
clinical Stage

Module 2: Pediatric HIV,

Child fulfilling any of the above criteria needs ART.
Diagnosis and Staging,
March 2011 56
 Total Lymphocyte Count (TLC)
 Where one cannot perform CD4 assays, TLC
provides a rough guide to level of
immunosuppression.

 As CD4 count drops, TLC also drops.

 This is only useful for baseline evaluation for

immunosuppression.

Module 2: Pediatric HIV, 57

Diagnosis and Staging,
 Computing Total Lymphocyte Count
 If WCC = 4.0 X 109/litre and differential
Lymphocyte count is 50%,
What is the total lymphocyte count?

(Give the TLC in two different units –

per litre and per mm3 ).

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
58
 Computing Total Lymphocyte Count

Answer
TLC = 50% of 4.0 x 109
i.e. 2.0 x 109 /litre.

Divide by 106 to convert TLC to per mm3

Above example,
TLC = (2.0 x 109) / 106 = 2,000/mm3
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
59
 Computing CD4%
CD4% = Absolute CD4 count per mm3 x 100
Total lymphocyte count per mm3

OR = Absolute CD4 count per litre x 100

Total lymphocyte count per litre

Module 2: Pediatric HIV,

Diagnosis and Staging,
March 2011
60
 Summary of Approach to Diagnosis

1. Do clinical assessment – suspect HIV.

2. Do clinical staging (WHO).
3. Do HIV antibody test;
If child< 18mth and antibody test is
positive, do PCR.
4. Do CD4 test.
5. If CD4 not available do TLC.
6. Make final diagnosis, and stage child’s
disease.
Module 2: Pediatric HIV,
Diagnosis and Staging,
March 2011
61
THANK YOU!!
Supplementary Slides
 Determine Assay
Apply 50L sample (Whole blood, Serum, Plasma)

PATIENT

Add 1 drop of Chase Buffer (Whole blood)

Allow to develop (15 min)

Interpret results
Module 2: Pediatric HIV, 72
Diagnosis and Staging,
Determine: Interpretation of Results
POSITIVE NEGATIVE INVALID INVALID
472U100 472U100 472U100 472U100

HIV-1/2 HIV-1/2 HIV-1/2 HIV-1/2

7A 7A 7A 7A
CONTROL

CONTROL

CONTROL

CONTROL
PATIENT

PATIENT
PATIENT

PATIENT

Module 2: Pediatric HIV, 73

Diagnosis and Staging,
 Uni-Gold Assay
Add 2 drops of Sample (Whole blood, Serum, Plasma)

Add 2 drops of Wash Reagent

Allow to develop (10 min)

Interpret results
Module 2: Pediatric HIV, 75
Diagnosis and Staging,
 `
Unigold:Interpretation of Results

POSITIVE NEGATIVE INVALID INVALID

Module 2: Pediatric HIV, 76

Diagnosis and Staging,
 WHO Proposed Immunological
Staging, 2006
Classification Age-related CD4 values
immune
deficiency <11 months 12-35 36-59 ≥5 yrs
(%) months (%) months (%) (cells/mm3)

Not Significant >35% >30% >25% >500

Mild 30-35% 25-30% 22-25% 350-499

Advanced 25-30% 20-25% 15-20% 200 - 349

Severe <25% <20% <15% <200 or

<15%
Module 2: Pediatric HIV, 89
Diagnosis and Staging,
 WHO 2010 Criteria for initiating
ART in children
Age in < 24 24–59 5 - 12yr > 12yr
months mth mth

By CD4 % ALL < 25% N/A N/A

By CD4 ALL < 750 < 350 < 350

count

WHO clinical ALL 3 or 4 3 or 4 3 or 4

Stage

Child fulfilling any of the above criteria needs ART.

Module 2: Pediatric HIV, 90
Diagnosis and Staging,