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Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring [Internet]. Geneva: World Health Organization; 2021 Mar.

Cover of Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring

Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring [Internet].

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Annex 2Simplified infant diagnosis algorithm

The key principles for establishing whether HIV-exposed infants and children younger than 18 months are infected with HIV in low- and middle-income countries are as follows.

  • Assess HIV exposure status by antibody testing the mother.
  • Perform nucleic-acid testing for any HIV-exposed child who presents outside the national infant testing algorithm with clinical symptoms, regardless of previous nucleic-acid test results
  • At nine months, perform nucleic-acid testing for HIV-exposed infants, symptomatic and asymptomatic, and even if previous nucleic-acid test results have been negative.
  • Ensure that indeterminate test results are repeat tested immediately and given priority for rapid resolution.
  • Ensure that confirmatory testing is undertaken following any positive result.
  • Ensure regular follow-up for all HIV-exposed infants until final diagnosis, including providing co-trimoxazole prophylaxis and clinical and nutritional assessment.
Image annex2f1

Notes:

a. Based on 2016 WHO Consolidated ARV Guidelines, addition of NAT at birth to the existing testing algorithm can be considered.

b. POC NAT can be used to diagnose HIV infection as well as to confirm positive results.

c. Start ART without delay. At the same time, retest to confirm infection. As maternal treatment is scaled up and MTCT transmission rates decrease, false-positive results are expected to increase: retesting after a first positive NAT is hence important to avoid unnecessary treatment, particularly in settings with lower transmission rates.

If the second test is negative, a third NAT should be performed before interrupting ART.

d. For children who were never breastfed, additional testing following a negative NAT at 4–6 weeks is included in this algorithm to account for potential false-negative NAT results.

e. The risk of HIV transmission remains as long as breastfeeding continues. If the 9-month test is conducted earlier than 3 months after cessation of breastfeeding, infection acquired in the last days of breastfeeding may be missed. Retesting at 18 months or 3 months after cessation of breastfeeding (whichever is later) should be carried out for final assessment of HIV status.

f. If breastfeeding extends beyond 18 months, the final diagnosis of HIV status can only be assessed at the end of breastfeeding. If breastfeeding ends before 18 months, the final diagnosis of HIV status with antibody testing can only be assessed at 18 months. Antibody testing should be undertaken at least 3 months after cessation of breastfeeding (to allow for development of HIV antibodies). For infants younger than 18 months of age NAT should be performed to confirm infection. If the infant is older than 18 months, negative antibody testing confirms that the infant is uninfected; positive antibody testing confirms infant is infected.

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