5.1 HIV testing and counselling
Consolidated ARV guidelines, June 2013
22.214.171.124 Infants and children
HIV-exposed infants and children younger than 18 months should be tested within four to six weeks of birth so that those already infected with HIV can start ART. Mortality is very high among untreated infants infected with HIV in the first year of life, making early HIV testing, prompt return of results and rapid initiation of treatment essential. In this population, HIV infection can only be definitively confirmed using virological tests because of the presence of persisting maternal HIV antibody in the child up to 15–18 months of age. Virological tests include assays to detect viral nucleic acid (HIV DNA, RNA or total nucleic acid) or p24 antigen.
Currently, virological testing is most commonly performed on dried blood spot (DBS) specimens, with collection at local sites and transport and testing at centralized laboratories. While early testing is increasing, there are ongoing challenges of access, return of results and initiation of early treatment in infants testing positive. Point-of-care virological testing, in development, is expected to greatly improve early diagnosis and treatment. Because some infants are not identified as HIV-exposed or are lost to postpartum follow-up, provider-initiated testing and counselling should be implemented in infant care settings for additional casefinding. Final diagnosis (or definitive diagnosis) at the end of the risk period for motherto- child transmission (breastfeeding period) should be ensured. A negative HIV antibody test in a known HIV-exposed infant can be useful to exclude HIV infection if there is no ongoing exposure. (See Annex 5 for the algorithm on HIV diagnosis in children less than 18 months of age.)
For children 18 months of age and older (who are not breastfeeding or who stopped breastfeeding at least six weeks earlier), standard HIV serological tests such as rapid diagnostic tests can be used to reliably determine HIV infection status. WHO recommends provider-initiated testing and counselling for all children who are malnourished, have TB, are admitted to hospital or have other signs or symptoms of HIV infection. Other approaches such as testing all children in childhood vaccination programmes have been implemented in some settings to increase chances of finding HIV-infected children. The recommendations on diagnosis of HIV infection in infants and children will be reviewed in the coming year.
Table 5.1 Summary of recommended testing approaches for infants (27)
Source for recommendations
WHO recommendations on the diagnosis of HIV infection in infants and children
Guideline on HIV disclosure counselling for children up to 12 years of age
Existing recommendations (27)
- It is strongly recommended that all infants with unknown or uncertain HIV exposure being seen in health care facilities at or around birth or at the first postnatal visit (usually 4–6 weeks), or other child health visit, have their HIV exposure status ascertained (strong recommendation, high-quality evidence).
- It is strongly recommended that all HIV-exposed infants have HIV virological testing at four to six weeks of age or at the earliest opportunity thereafter (strong recommendation, high-quality evidence).
- For infants with an initial positive virological test result, it is strongly recommended that ART be started without delay and, at the same time, a second specimen be collected to confirm the initial positive virological test result. Do not delay ART. Immediate initiation of ART saves lives and should not be delayed while waiting for the results of the confirmatory test (strong recommendation, high-quality evidence).
- It is strongly recommended that infants with signs or symptoms suggestive of HIV infection undergo HIV serological testing and, if positive (reactive), virological testing (strong recommendation – low-quality evidence).
- It is strongly recommended that well, HIV-exposed infants undergo HIV serological testing at around nine months of age (or at the time of the last immunization visit). Infants who have reactive serological assays at nine months should have a virological test to identify HIV-infected infants who need ART (strong recommendation, low-quality evidence).
- It is strongly recommended that children 18 months of age or older with suspected HIV infection or HIV exposure, have HIV serological testing performed according to the standard diagnostic HIV serological testing algorithm used in adults (strong recommendation, high-quality evidence).
Existing recommendation (28)
- Children of school age should be told their HIV-positive status and their parents or caregiver’s status; younger children should be told their status incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure (strong recommendation, low-quality evidence).