Manage HIV/AIDS using IMCI approach

Manage HIV/AIDS using IMCI approach

CHECK FOR HIV EXPOSURE AND INFECTION

All children found to have pneumonia, persistent diarrhea, ear discharge or very low weight for age (any of these features) and have no urgent need or indication for referral, should be assessed for symptomatic HIV infection. 

  • Children may acquire HIV infection from an infected mother through vertical transmission in utero, during delivery or while breastfeeding.
  • Without any intervention, 30 – 40% babies born to infected mothers will themselves be infected.
  • Most children born with HIV die before they reach their fifth birthday, with most not surviving beyond two years.
  • Good treatment can make a big difference to children with HIV and their families.
  • The child’s status may also be the first indicator that their parents are infected too.

ASSESS FOR HIV EXPOSURE AND INFECTION 

ASK

LOOK, FEEL AND DIAGNOSE

• Ask for mother’s HIV status to establish child’s HIV exposure* 

Is it: 

Positive, Negative or Unknown (to establish child’s HIV exposure) 

 

• Ask if child has had any TB Contact

Child <18 months 

• If mother is HIV positive**, conduct DNA PCR for the baby at 6 weeks or at first contact with the child 

• If the mother’s HIV status is unknown, conduct an antibody test (rapid test) on the mother to determine HIV exposure. 

PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV INFECTION IN CHILDREN <18 MONTHS 

• Pneumonia *** 

• Oral Candidiasis /thrush 

• Severe sepsis 

• Other AIDS defining conditions**

 

Child ≥18 months 

• If the mother’s antibody test is POSITIVE, the child is exposed. Conduct an antibody test on the child. 

 

Child whose mother is NOT available: 

• Child < 18 months 

Do an antibody test on the child. If positive, do a DNA PCR test. 

• Child ≥ 18 months 

Do an antibody test to determine the HIV status of the child

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

TREATMENT

• Child < 18 months and DNA PCR test POSITIVE 

 

• Child ≥ 18 months and Antibody test POSITIVE 

CONFIRMED HIV INFECTION

• Initiate ART, counsel and follow up existing infections 

• Initiate or continue cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development and HIV services 

• Educate caregivers on adherence and its importance 

• Screen for possible TB disease at every visit. 

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB throughout IPT 

• Immunize for measles at 6 months and 9 months and boost at 18 months 

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

Child<18 months 

• If mother test is positive and child’s DNA PCR is negative OR 

• If mother is unavailable; child’s antibody test is positive and DNA PCR is negative

HIV EXPOSED

• Treat, counsel and follow up existing infections 

• Initiate or continue Cotrimoxazole prophylaxis 

• Give Zidovudine and Nevirapine prophylaxis as per the national PMTCT guidelines 

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver  

• Offer routine follow up for growth, nutrition and development 

• Repeat DNA PCR test at 6 months. If negative, repeat DNA PCR test again at 12 months. If negative, repeat antibody test at 18 months

• Continue with routine care for under 5 clinics 

• Screen for possible TB at every visit 

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

• No test results for child or mother 

• 2 or more of the following conditions: 

• Severe pneumonia 

• Oral candidiasis/thrush 

• Severe Sepsis

 OR

• An AIDS defining condition

SUSPECTED SYMPTOMATIC HIV INFECTION

• Treat, counsel and follow-up existing infections

• Give cotrimoxazole prophylaxis

• Give vitamin A supplements from 6 months of age every 6 months

• Assess the child’s feeding and provide appropriate counseling to the mother

• Test to confirm HIV infection

• Refer for further assessment including HIV care/ ART

• Follow-up in 14 days, then monthly for 3 months and then  every 3 months or as per immunization schedule 

Mother’s HIV status is NEGATIVE 

OR 

Mother’s HIV status is POSITIVE and child is ≥ 18 months with antibody test NEGATIVE 6 weeks after completion of breastfeeding

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines 

• Advise the mother about feeding and about her own health

THEN CHECK FOR TB

ASK

LOOK AND FEEL

For symptoms

suggestive of TB

  • Has the child been coughing for 14 days or more?

  • Has the child had persistent fever for 14 days or more?

  • Has the child had poor weight gain in the last one month?*

History of contact

  • Has the child had contact with a person with Pulmonary Tuberculosis or chronic cough?

Look or feel for physical signs of TB

  • Swellings in the neck or armpit

  • Swelling on the back

  • Stiff neck

  • Persistent wheeze not responding to

brochodilaters.

Collect sample for GeneXpert or smear microscopy

 

If available, send the child for laboratory tests (GeneXpert or smear microscopy) and/ or Chest X-Ray.

CLASSIFY

SIGNS

CLASSIFY AS

TREATMENT

Two or more of the following in HIV Negative child AND one or more of the following in HIV

Positive child:

  • At least two symptoms suggestive of TB

  • Positive history of contact with a TB case

  • Any physical signs suggestive of TB

OR

  • A positive GeneXpert or smear microscopy test

TB

• Initiate TB treatment

• Treat, counsel, and follow up any

co- infections

• Ask about the caregiver’s health and

treat as necessary

• Link the child to the nearest TB clinic

for further assessment and ongoing

follow-up

• If GeneXpert or smear microscopy

test is not available or negative,

refer for further assessment

Positive history of contact with a TB case and

NO other TB symptoms or signs listed above

TB

EXPOSURE

• Start Isoniazid at 10mg/kg for 6

months

• Treat, counsel, and follow up

existing infections

• Ask about the caregiver’s health and

treat as necessary

• Link child to the nearest TB clinic

NO TB symptoms or signs

NO TB

• Treat, counsel, and follow up

existing infections 

• Start Isoniazid in HIV positive child

above 1 year at 10mg/kg for 6

months

THEN CHECK THE CHILD‘S IMMUNIZATION AND VITAMIN A STATUS

Immunization Schedule

  • Follow National Guidelines as per the Child Health Card/Mother Baby Passport.

Age

Vaccine

Birth

BCG*

 

OPV-0

6 weeks

DPT+HepB+HIB

 

OPV-1

RTV1

PCV1

10 weeks

DPT+HepB+HIB

 

OPV-2

RTV2

PCV2

14 weeks

DPT+HepB+HIB

 

OPV-3

IPV

RTV3

PCV3

9 months

Measles

 

  • BCG: Bacillus Calmette-Guérin (given at birth)
  • OPV: Oral Polio Vaccine
  • DPT: Diphtheria, Pertussis, Tetanus
  • HepB: Hepatitis B
  • HIB: Haemophilus influenzae type b
  • RTV: Rotavirus Vaccine
  • PCV: Pneumococcal Conjugate Vaccine
  • IPV: Inactivated Polio Vaccine

VITAMIN A SUPPLEMENTATION

Give every child a dose of Vitamin A every six months from the age of 6 months.

Record the dose on the child’s chart.

ROUTINE DEWORMING TREATMENT

Give every child mebendazole every six months from the age of 1 year. Record the dose on the child’s chart.

 

Manage HIV/AIDS using IMCI approach

  • All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage. 
  • Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.

Steps when Initiating ART in Children 

STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION 

Child is under 18 months: 

  • HIV infection is confirmed if virological test (PCR) is positive.

Child is over 18 months: 

  • Two different serological tests are positive.
  • Send any further confirmatory tests required.

If results are discordant, refer 

If HIV infection is confirmed, and child is in stable condition, GO TO STEP 2

 

STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART

Check that the caregiver is willing and able to give ART. The caregiver should ideally have  disclosed the child’s HIV Status to another adult who can assist with providing ART, or be part of a support group.

  • Caregiver able to give ART: GO TO STEP 3
  • Caregiver not able: classify as CONFIRMED HIV INFECTION

but NOT ON ART. Counsel and support the caregiver. Follow-up regularly. Move to STEP 3 once the caregiver is willing and able to give ART.

 

STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
  • If a child is less than 3 kg or has TB, Refer for ART initiation.
  • If child weighs 3 kg or more and does not have TB, GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION ON THE CHILD’S HIV TREATMENT CARD

Record the following information:

  • Weight and height
  • Pallor if present
  • Feeding problem if present
  • Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests that are required. Do not wait for results. GO TO STEP 5
STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS
  • Initiate ART treatment:
  1. Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
  2. Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
  • Give co-trimoxazole prophylaxis
  • Give other routine treatments, including Vitamin A and immunizations
  • Follow-up regularly as per national guidelines.

Recommended First-Line ARV Regimens

Patient Category

Indication

ARV Regimen

Adults and Adolescents (aged 10 and above)

Initiating ART

TDF+3TC+EFV

 

Alternative Regimens

TDF+3TC+DTG (Contraindications for EFV)

ABC+3TC+DTG (Contraindications for TDF)

Pregnant or Breastfeeding Women

Initiating ART

TDF+3TC+EFV

 

Alternative Regimen

ABC+3TC+ATV/r (Contraindications for TDF or EFV)

Children (3 to <10 years)

Initiating ART

ABC+3TC+EFV

 

Alternative Regimen

ABC+3TC+NVP (Contraindications for EFV)

Children Under 3 Years

Initiating ART

ABC+3TC+LPV/r

 

Alternative Regimen

AZT+3TC+LPV/r (Hypersensitivity reaction to ABC)

Second- and Third-Line ART Regimens

Population

Patients Failing First-Line Regimens

Second-Line Regimens

Third-Line Regimens

Adults, Pregnant and Breastfeeding Women, Adolescents

TDF + 3TC + EFV

AZT+3TC+ATV/r (recommended) or AZT+3TC+LPV/r (alternative)

All 3rd line regimens guided by resistance testing

  

If not exposed to INSTIs: DRV/r + DTG ± 1-2 NRTIs

If exposed to INSTIs: DRV/r + ETV±1-2 NRTIs

TDF + 3TC + DTG

 

ABC+ 3TC+ DTG

ABC+ 3TC+ EFV

ABC/3TC/NVP

TDF/3TC/NVP

AZT/3TC/NVP

 

TDF+3TC+ATV/r (recommended) or TDF+3TC+LPV/r

AZT/3TC/EFV

Children (3–<10 years)

ABC + 3TC + EFV

AZT+3TC+LPV/r

For children above 6 years, and prior exposure to INSTIs, DRV/r±1-2 NRTIs

  

ABC+ 3TC + NVP

AZT+3TC+NVP

ABC+3TC+LPV/r

For children below 6 years, AZT/3TC/EFV

 
 

DRV/r+ RAL+ 2 NRTIs

AZT+3TC+LPV/r

Children Under 3 Years

ABC+3TC+LPV/r pellets

AZT+3TC+RAL

Optimize regimen using genotype profile

  

AZT+3TC+LPV/r pellets

ABC+3TC+RAL

 

AZT+3TC+NVP

ABC+3TC+LPV/r

 
Principles for Selecting ARV Regimens:
  • Lower toxicity
  • Better palatability and lower pill burden
  • Increased durability and efficacy
  • Sequencing to spare other formulations for the 2nd line regimen
  • Harmonization across age and population
  • Lower cost
  • Facilitate achieving a recommended regimen for the majority of PLHIV
Rationale for Alternative Regimens:
  • TDF+3TC+DTG: EFV contraindications
  • ABC+3TC+DTG: TDF contraindications
  • ABC+3TC+ATV/r: Contraindications for TDF or EFV
  • ABC+3TC+NVP: EFV contraindications in children (3 to <10 years)
  • AZT+3TC+LPV/r: Hypersensitivity reaction to ABC (rare)
Considerations:
  • Dolutegravir (DTG) benefits: low potential for drug interactions, shorter time to viral suppression, higher resistance barrier, long half-life, and low cost.
  • ABC+3TC+EFV once-a-day dose for improved adherence.
  • LPV/r-based regimen for children under 3 years due to reduced risks and high resistance barrier.

ABC: Abacavir

AZT: Zidovudine

3TC: Lamivudine

LPV/r: Lopinavir/Ritonavir

RTV: Ritonavir

NVP: Nevirapine

EFV: Efavirenz

DTG: Dolutegravir

TDF: Tenofovir Disoproxil Fumarate

RAL: Raltegravir

ATV/r: Atazanavir/Ritonavir

 

TB/HIV Co-Infection Treatment Based on Age/Weight

AGE/WEIGHT

FIRST LINE TB/HIV CO-INFECTION

< 2 Weeks

Start TB treatment immediately, start ART (Usually after 2 weeks of age) once tolerating TB drugs

> 2 Weeks and <35 kgs

ABC/3TC/LPVr/RTV If not able to tolerate super boosted LPVr/RTV then use ABC/3TC + RAL for duration of TB treatment. After completion of TB treatment revert back to the recommended 1st line regimen ABC/3TC +LPVr.

If on ABC/3TC/EFV regimen – continue If on NVP based regimen, change to EFV.

>35 kgs body weight and < 15 years age

ABC/3TC/DTG continue with the regimen AND double the dose for DTG If on PI based regimen switch the patients to DTG, hence doubling the dose

DOSAGE OF COTRIMOXAZOLE PROPHYLAXIS

WEIGHT (KG)

SUSPENSION 240MG PER 5ML

SINGLE STRENGTH TABLET 480MG (SS)

DOUBLE STRENGTH TABLET 960MG (DS)

1-4

2.5ml

1/4 SS tab

–

5-8

5ml

1/2 SS tab

1/4 DS tab

9-16

10ml

1 SS tab

1/2 DS tab

17-30

15ml

2 SS tab

1 DS

>30(Adults and adolescents)

–

2 SS

1 DS

Dose by body weight is 24-30 mg/kg once daily of the trimethoprim-sulphamethaxazole – combination drug.

• Oral thrush management– use miconazole gel 

• Cotrimoxazole use is still recommended 

• Most infants and children initiated on treatment take time before immune recovery occurs 

• Children on LPV/r – continue with boosted ritonavir 

• RAL – for those unable to tolerate super boosted LPV/r

 

Paediatric ARVs Dosages

WEIGHT RANGE (KG)

ABACAVIR + LAMIVUDINE

120 mg ABC + 60 mg 3TC

ZIDOVUDINE + LAMIVUDINE

60 mg ZDV + 30 mg 3TC

EFAVIRENCE (EFV) 

Once Daily 200mg tabs

LAMIVUDINE + ZIDOVUDINE

Twice Daily 200mg tabs

3 – 5.9

0.5 tab

1 tab

–

 

6 – 9.9

1 tab

1.5 tabs

–

 

10 – 13.9

1 tab

2 tabs

1 tab 

1.5 tabs

14 – 19.9

1.5 tabs

2.5 tabs

1.5 tabs 

+ 1 tab in AM & 0.5 tab in PM

20 – 24.9

2 tabs

3 tabs

1.5 tabs 

1 tab in AM & 0.5 tab in PM

25 – 34.9

300 mg ABC + 150 mg 3TC

300 mg ZDV + 150 mg 3TC

2 tabs 

1 tab in AM & 0.5 tab in PM

 

Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS

APPROPRIATE CARE RESPONSE

Yellow eyes (jaundice) or abdominal pain

Stop drugs and REFER URGENTLY

Rash

If on abacavir, assess carefully. Call for advice. If severe, generalized, or associated with fever or vomiting: stop drugs and REFER URGENTLY

Nausea

Advise drug administration with food. If it persists for more than 2 weeks or worsens, call for advice or refer.

Vomiting

If medication is seen in vomitus, repeat the dose. If vomiting persists, bring the child to the clinic. REFER URGENTLY if vomiting everything or associated with severe symptoms.

Diarrhoea

Assess, classify, and treat using diarrhoea charts. Reassure that it may improve in a few weeks. Follow up as per chart booklet. Call for advice or refer if not improved after two weeks.

Fever

Assess, classify, and treat using fever chart.

Headache

Give paracetamol. If on efavirenz, reassure that it is common and usually self-limiting. Call for advice or refer if it persists for more than 2 weeks or worsens.

Sleep disturbances, nightmares, anxiety

Due to efavirenz. Administer at night on an empty stomach with low-fat foods. Call for advice or refer if it persists for more than 2 weeks or worsens.

Tingling, numb, or painful feet or legs

If new or worse on treatment, call for advice or refer.

Changes in fat distribution

Consider switching from stavudine to abacavir, consider viral load. Refer if needed.

GIVE FOLLOW – UP CARE FOR ACUTE CONDITIONS 

  • Care for the child who returns for follow-up using all the boxes that match the child’s previous classifications.

  • If the child has any new problem, assess, classify fully and treat as on the ASSESS AND CLASSIFY chart.

PNEUMONIA

After 2 days

Check the child for general danger signs.

Assess the child for cough or difficult breathing.

Ask:

  • Is the child breathing slower?
  • Is there less fever?
  • Is the child eating better?

Treatment:

  • If any general danger sign, administer a dose of second-line antibiotic, then admit or refer URGENTLY to the hospital.
  • If chest indrawing, breathing rate, fever, and eating have not improved, switch to the second-line antibiotic and ADMIT or REFER (If this child had measles within the last 3 months or is known or confirmed HIV infection, refer).
  • If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.
WHEEZING

After 2 days

Check the child for general danger signs or chest indrawing.

Assess the child for cough or difficult breathing.

Ask:

  • Is the child breathing slower?
  • Is the child still wheezing?
  • Is the child eating better?

For Children under 1 year:

  • If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

  • Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
  • If no wheezing, breathing slower, and eating better; continue the treatment for 5 days.

For Children over 1 year:

  • If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

  • Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
  • If breathing rate and eating have not improved; change to second-line antibiotic and ADMIT OR REFER urgently to the hospital.
  • If still wheezing; continue oral bronchodilator.
  • If breathing slower, no wheezing, and eating better, continue the treatment for 5 days.
  • If the child has unilateral wheeze and is not responding to bronchodilators, TB disease is likely and should be evaluated.
PERSISTENT DIARRHOEA

After 5 days

Ask:

  • Has the diarrhea stopped?
  • How many loose stools is the child having per day?

Treatment:

  • If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to the hospital.
  • If the diarrhea has stopped (child having fewer than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child’s age, but give one extra meal every day for 1 month. Ask her to continue giving Zinc sulfate for a total of 10 days.
  • NB: Attention to diet is an essential part of the management of a child with persistent diarrhea
DYSENTERY

After 2 days

Assess the child for diarrhea. > See ASSESS & CLASSIFY chart

Ask:

  • Are there fewer stools?
  • Is there less blood in the stool?
  • Is there less fever?
  • Is there less abdominal pain?
  • Is the child eating better?

Treatment:

  • If the child is dehydrated, treat dehydration according to classification.
  • If the number of stools, the amount of blood in stools, fever, abdominal pain, or eating is worse: Admit or Refer to the hospital.

If the condition is the same: add Metronidazole to the treatment. Give it for 5 days. Advise the mother to continue ciprofloxacin and zinc and to return in 2 days.

  • Exceptions – if the child:

    • is less than 12 months old, or 

    • was dehydrated on the first visit or to the hospital.

    • had measles within the last 3 months , then Admit or Refer URGENTLY

  • If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving Ciprofloxacin and zinc sulfate until finished.
UNCOMPLICATED MALARIA

If fever persists after 3 days, or recurs within 14 days:

Do a full reassessment of the child. >See ASSESS & CLASSIFY chart. Assess for other causes of fever. 

Treatment:

  • If the child has any general danger sign or stiff neck, treat it as VERY SEVERE FEBRILE DISEASE.
  • If the child has any cause of fever other than malaria, provide treatment.
  • If malaria is the only apparent cause of fever and confirmed by microscopy: Give oral DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ). Give paracetamol. If the child is under 5 kg and was given DHA-PPQ assess further.
  • Advice mother to return again in 3 days if the fever persists – If fever has been present every day for 7 days, refer for assessment.
FEVER – NO MALARIA

If fever persists after 3 days:

Do a full reassessment of the child. > See ASSESS & CLASSIFY chart (see pg 6) Assess for other causes of fever.

Treatment:

  • If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
  • If the child has any cause of fever other than malaria, provide appropriate treatment.
  • If malaria is the only apparent cause of fever:

    • Treat with the first-line oral antimalarial. Give paracetamol. Advise the mother to return again in 3 days if the fever persists.

    • If fever has been present every day for 7 days, refer for assessment.

  • If the child has persistent fever, cough, and reduced playfulness despite other treatment, evaluate for TB.

EYE OR MOUTH COMPLICATIONS OF MEASLES

After 2 days:

Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth.

Treatment for Eye Infection:

  • If pus is draining from the eye, ask the mother/caregiver to describe how she has treated the eye infection.
  • If treatment has been correct, refer to the hospital. If treatment has not been correct, teach mother/caregiver correct treatment.
  • If the pus is gone but redness remains, continue the treatment.
  • If there is no pus or redness, stop the treatment.

Treatment for Mouth Ulcers:

  • If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to the hospital.
  • If mouth ulcers are the same or better, continue using half-strength gentian violet or Nystatin for a total of 5 days.

Treatment for thrush:

  • If thrush is worse, check that treatment is being given correctly.
  • If the child has problems with swallowing, refer to the hospital.
  • If thrush is the same or better, and the child is feeding well, continue Nystatin for a total of 7 days.
  • If thrush is no better or is worse consider symptomatic HIV infection.
EAR INFECTION

After 5 days:

Reassess for ear problem. > See ASSESS & CLASSIFY chart Measure the child’s temperature.

Treatment:

  • If there is tender swelling behind the ear or high fever (38.5°C or above), admit or refer URGENTLY to the hospital.
  • Acute ear infection: if ear pain continues or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.
  • Chronic ear infection: Check that the mother is wicking the ear correctly. Encourage her to continue. Review in 2 weeks.
  • If ear discharge continues for more than 2 months: Admit or refer to the hospital.
  • If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the 5 days of antibiotic, tell her to use till treatment is completed.
FEEDING PROBLEM

After 5 days:

Reassess feeding. See questions at the top of the COUNSEL THE MOTHER. Ask about any feeding problems found on the initial visit.

  • Counsel the mother/caregiver about any new or continuing feeding problems. If you counsel the mother/caregiver to make significant changes in feeding, ask her to bring the child back again after 5 days.
  • If the child is very low weight for age, ask the mother to return 14 days after the initial visit to measure the child’s weight gain.
PALLOR 

After 14 days:

  • Give iron and folate. Advise mother to return in 14 days for more iron and folate.
  • Continue giving iron and folate every day for 2 months.
  • If the child has palmar pallor after 2 months, refer for assessment.
MALNUTRITION 

After 14 days:

If the child is gaining weight, encourage the mother to continue with feeding. Counsel the mother about any feeding problem.

SEVERE MALNUTRITION WITHOUT COMPLICATIONS 

After 7 days or during regular follow-up:

  • Do a full assessment of the child >See ASSESS AND CLASSIFY chart.
  • Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
  • Check for edema of both feet.
  • Check the child’s appetite by offering ready-to-use therapeutic food if the child is 6 months and older.

Treatment:

  • If the child has SEVERE MALNUTRITION WITH COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5mm or edema of both feet AND has developed a medical complication or edema, or fails the appetite test), refer URGENTLY to the hospital.
  • If the child has SEVERE MALNUTRITION WITHOUT COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5 mm or edema of both feet but NO medical complication and passes the appetite test) counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask the mother to return in 7 days.
  • If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC between 11.5 and 12.5 mm), advise the mother to continue RUTF. Counsel the mother.

MODERATE ACUTE MALNUTRITION

 After 14 days:

  • Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit.
  • If WFH/L, weigh the child, measure height or length and determine if WFH/L.
  • If MUAC, measure using MUAC tape.
  • Check the child for edema of both feet.
  • Reassess feeding. See questions in the COUNSEL THE MOTHER chart.

Treatment:

  • If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and encourage her to continue.
  • If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any feeding problem found. Ask the mother to return again in 14 days. Continue to see the child every 2 weeks until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or MUAC is 12.5 or more.
  • Assess all children with failure to thrive or growth faltering for possible TB disease. Exception: If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has diminished, refer the child.
HIV EXPOSED & INFECTED CHILDREN

HIV INFECTED CHILD

After 1 month:

  • Assess the child’s general condition. Do a full assessment
  • Treat the child for any condition found.
  • Ask for any feeding problems, counsel the mother about any new or continuing feeding problems.
  • Advise the mother/caregiver to bring the child back if any new illness develops or she is worried.
  • Counsel the mother/caregiver on any other problems and ensure community support is being given. Refer for further psychosocial/counseling if necessary.
  • Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
  • Assess adherence to ART and Cotrimoxazole and advise accordingly.
  • Offer or refer child for comprehensive HIV management and care (including ART) as per the national ART guidelines.
  • Plan for defaulter tracking system; identification and tracking of children.
  • Follow up monthly.

HIV EXPOSED CHILD (<18 months): For children tested DNA PCR Negative

After 1 month:

  • Assess the child’s general condition. Do a full reassessment.
  • Ask for any feeding problems or poor appetite, counsel the mother about any new or continuing feeding problems.
  • Treat the child for any condition found.
  • Give Cotrimoxazole prophylaxis from 6 weeks and emphasize the importance of compliance.
  • Start or continue with ARV prophylaxis for a total of 12 weeks.
  • Screen for possible TB Disease.
  • Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
  • Follow-up schedule of HIV Exposed infant monthly up to 24 months.
  • Refer to Early Infant Diagnosis (EID) algorithm for confirmation of HIV status.
  • Refer to the HIV exposed infant follow-up card and register for further follow-up instructions.

Feeding Counseling

For Mothers and caregivers of infants under 18 months.

Goals:

  • Discuss ongoing HIV risk from breastfeeding and the implications on test results.
  • Support the mother as she makes choices about feeding for the infant.
  • Ensure that the mother understands the testing procedure for infants under 18 months.
  • If positive, discuss the need to start ART immediately.

Just after giving birth, the mother should be counseled on:

  • HIV testing for herself: if she did not test in antenatal, she should be tested soon after delivery.
  • Infant feeding practices.
  • HIV testing for the infant: at 6 weeks, the infant can be tested.

Overview of Infant Feeding Guidelines for Exposed Infants

  • HIV+ mothers should exclusively breastfeed infants for the first 6 months.
  • Complementary feeds should be introduced from 6 months.
  • Continue to breastfeed for 12 months.
  • During breastfeeding, the infant should receive daily NVP until 1 week after stopping breastfeeding.
  • Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.
  • When an infected mother decides to stop breastfeeding at any time, they should do so over the course of 1 month.
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