MAJOR RECOMMENDATIONS

Responsibilities of Child Healthcare Providers

As part of the initial newborn evaluation, the pediatric clinician should determine whether human immunodeficiency virus (HIV) testing of the mother has been completed properly and should follow up on any outstanding laboratory values.

Pediatric clinicians should obtain testing for HIV beyond the neonatal period if the child presents with signs and symptoms of HIV disease. Testing should be performed in children who have not yet been tested when risk factors for HIV infection exist in the child or one of his/her parents.

Laboratory Tests for HIV in Newborns, Children, and Adolescents

Because positive antibody results alone do not establish infection in children younger than 18 months of age, assays to detect virus (HIV deoxyribonucleic acid [DNA] polymerase chain reaction [PCR] or viral culture) should be used for diagnosis (see Figure 1 in the original guideline document).

In children older than 18 months of age, HIV infection may be diagnosed on the basis of a positive HIV antibody test (enzyme-linked immunosorbent assay [ELISA]) and a confirmatory test, such as Western blot.

Because of the time period between infection and the development of detectable antibodies, children/adolescents exposed via sexual activity, sexual abuse/assault, or infected blood who have an initial negative test result should be retested at 1 month, 3 months, and 6 months after exposure.

Because a child with end-stage HIV disease may become HIV-antibody seronegative as a result of severe humoral immunodeficiency, children who are clinically suspected to be HIV-infected yet test HIV antibody negative should be tested by DNA PCR (or HIV culture).

Children older than 18 months of age with an indeterminate Western blot result should be retested as soon as possible. If the Western blot result remains indeterminate, the patient should be tested for HIV-2 or specific viral tests (e.g., DNA PCR) for HIV-1 should be performed.

Rapid testing and expedited preliminary test results prior to Western blot confirmation should generally be used only when immediate information is needed to determine the need for post-exposure prophylaxis in the labor/delivery, newborn, or other acute exposure settings, or when the person who is being tested is unlikely to return for a follow-up visit.

When preliminary diagnostic tests are used for expedited HIV testing, a preliminary positive test result must be confirmed with a Western blot as soon as possible.

Testing for HIV Antibody

See the original guideline document for discussions of screening tests, confirmatory testing of positive results, and rapid test assays.

Testing for HIV or Viral Components

Clinicians should test children younger than 18 months of age who are born to an HIV-infected mother for HIV using one of the following methods:

* HIV DNA PCR (preferred method)

* HIV culture (acceptable method)

Because infection can only be confirmed with two positive test results performed on samples collected at different times, a repeat sample should be obtained promptly for any child with a single positive test result.

In an infant younger than 18 months of age, HIV can be reasonably excluded with two negative HIV viral tests, one at 1 month of age or older, and the other at age 4 months or older.

Ideally, a DNA PCR should be obtained for HIV-exposed infants at each of the following time points:

* at birth

* at 2 weeks of age

* at 4 to 6 weeks of age

* at 6 to 12 weeks of age

* at 4 to 6 months of age

See the original guideline for discussions of HIV DNA PCR, HIV culture, plasma HIV RNA, and HIV antigen detection.

HIV Counseling and Testing

In New York State, written informed consent from the child’s biological parent or legal guardian must be obtained before HIV testing can be performed in children except in certain specific circumstances, such as expedited testing, newborn screening, and follow-up PCR testing, and when testing is urgently necessary to provide medical care for a life-threatening condition.

When HIV testing of a child is performed, the parents should be considered for testing as well.

If a child is found to be perinatally HIV infected, his/her siblings also should be tested.

If HIV infection is newly diagnosed in a woman, all of her children should be strongly considered for testing, even if they are asymptomatic.

Pre-Test Counseling

The clinician should counsel the child’s parent or guardian or the child/adolescent with capacity to consent prior to HIV testing (see Table 2 in the original guideline document).

In New York State, a minor’s right to consent for or refuse HIV testing is based on his/her capacity to understand, without regard to chronological age, what an HIV antibody test actually tests for, the implications/consequences of being HIV infected, and why he/she is at risk for HIV.

The clinician should arrange for follow-up visits at the time of testing and should note in the patient’s medical record that counseling was provided and written consent was obtained when required.

When rapid testing is obtained and will yield a preliminary result during the visit, the clinician should first ensure that the patient/parent is emotionally able to receive a positive result and that mental health services are available for patients receiving a positive result.

Obtaining Consent

See the original guideline document for a discussion New York State laws on obtaining consent for HIV testing in children and adolescents for HIV testing.

Post-test Counseling

Counseling after a Patient Receives a Positive Test Result

Positive HIV test results should be presented in person to the appropriate individual (patient, parent, or guardian). A clinician should not communicate results to a patient or family member by telephone or mail.

Clinicians must respect an adolescent’s right to confidentiality concerning HIV status.

The clinician should explain the test results and should provide general information about available treatment.

The clinician should discuss the implications of the HIV Reporting/Partner Notification law (refer to the section “HIV Reporting and Partner Notification” below).

The clinician should provide or arrange for necessary referrals for treatment and supportive services.

The clinician should discuss methods of risk reduction and advise the family to inform medical personnel of the child’s HIV status during any medical care visit.

Counseling After the Patient Receives a Negative Test Result

When telling a patient that his/her test result is negative, the clinician should educate the patient on how to reduce the risk of transmission in the future.

HIV Reporting and Partner Notification

Since June 2000, New York State has required HIV reporting and partner notification for all confirmed positive HIV tests (unless testing occurred at an anonymous site) and HIV-related tests.

During pre-test counseling, parents/children should be informed that if their HIV test result is positive, their names will be reported to the New York State Department of Health.

Parents/children should be informed during pre-test counseling that if they provide the names of sexual or needle-sharing partners, the provider is required to report these names to the State Health Department. They should also be informed that if the test results are positive, their partners will be notified that they have been exposed to HIV.

All sexually active HIV-infected adolescents should be informed about the importance and benefits of notifying partners of their possible exposure to HIV.

Adolescents who are undergoing HIV testing should be questioned regarding the potential for domestic violence if their partners were notified. If domestic violence is a concern, partner notification should be deferred until the risk of harm to the patient (or one close to the patient, e.g., child) is eliminated.

HIV Testing of Older Children and Adolescents With the Capacity to Consent

Clinicians should be knowledgeable about New York State laws pertaining to adolescent consent and confidentiality and should educate their patients about these laws (see the National Guideline Clearinghouse (NGC) summary of the New State Department of Health guideline Identification and Ambulatory Care of HIV-exposed and -infected Adolescents).

In New York State, older children and adolescents who are judged capable of understanding the informed consent process may give written informed consent for HIV testing.

Parents cannot be informed of their child’s HIV test results without the explicit consent of the child or adolescent who is deemed capable of providing consent.

Ideally, HIV testing of older children and adolescents should occur in a comprehensive care setting that provides social support, ancillary services, and ongoing health care.

HIV Testing in Children in Foster Care

Within 5 days of entering the foster care system, all children must be assessed for capacity to consent for HIV testing. If a child is determined not to have capacity to consent, an HIV risk assessment must also be completed within the first 5 days of entering foster care. Children already in foster care must be assessed for HIV risk factors at least 60 days prior to their next scheduled periodic medical examination. If it is determined that a child may have the capacity to consent, an assessment of capacity to consent must be made and documented by authorized foster care agency staff within 30 days of the child’s entry into foster care. An HIV risk assessment must also be completed within this timeframe.

If one or more risk factors are present, a child in foster care should be offered HIV testing, or if the child lacks capacity to consent, he/she should be tested for HIV infection.

Adolescents and older children in foster care with the capacity to consent for HIV testing have the right to either consent for their own test or refuse testing.

For the commplete article, please refer to http://www.guidelines.gov/summary/summary.aspx?doc_id=6834