HIV in children and adolescents in the context of COVID-19

 

Prepared by Dr Tammy Meyers, Dr Nicholas Medland (RAG Chair) and members of the Regional Advisory Group.

UPDATED ON: 1 September 2020

 

 

Disclaimer: The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings. The recommendations are not intended to replace national guidance.

 

 

 

 

 

Data are, as yet, unavailable to inform whether SARS CoV-2 affects HIV-infected children/adolescents differently from HIV-uninfected children and adolescents.

The COVID-19 pandemic threatens the achievements made towards the global UNAIDS 90-90-90 targets.  In the Asia Pacific region (APR), 78% of children and younger adolescents (0-14 years) living with HIV were receiving treatment compared to 56% adults in 2018.  Despite the progress in children globally, adolescents living with HIV (ALHIV) continue to fall behind adults in reaching HIV testing, antiretroviral therapy (ARV), and viral suppression targets.  Poor access to HIV services for adolescents and youth in the region is part of a much broader issue involving limited availability of sexual reproductive services (SRH) and poor implementation of comprehensive sexuality education (CSE), leaving adolescents vulnerable to blood borne virus (BBV) infections such as HIV. 
 

Recommendations for HIV services for children and adolescents (based on regional guidance from UNICEF/WHO and UNFPA): (4)

Access to essential HIV prevention and treatment services must continue albeit in an altered fashion to reduce exposure to COVID-19 

Diagnosis

  • HIV-exposed infants should continue to receive early infant diagnosis tests and clinical assessment as close to the recommended timing as possible (as described in a previous ASHM document on EPTCT HIV, Syphilis and HBV in the context of COVID-19). (5)
  • Access to in-person diagnosis for children and adolescents where HIV-exposure is suspected should continue to be made available (index testing for biological children of PLHIV recommended)
  • HIV self-testing (HIVST) – HIVST is not recommended for children. However for adolescents, where available and in settings where they can legally consent for their own testing, HIVST should be encouraged for adolescents as long as contact with healthcare providers is available and arrangements can be made for confirmatory testing or linkage to care and prescription for ARVs for treatment or PrEP/PEP if needed. (6)

 

Treatment

  • Ensure early access to care and treatment, including same-day ART initiation, if HIV infected 
  • HIV-exposed infants should be dispensed the full quantity of prophylaxis, both ART and cotrimoxazole, in environments where lockdown is ongoing or access to clinics limited
  • Provide mother-baby packs for the mother-infant pair together and follow up by phone
  • Multi-month supplies of ARVs, tuberculosis medication, and treatment for other chronic diseases should be given, with telehealth follow-up/support, for at least 3 months, for all clinically stable children, adolescents or pregnant and breastfeeding girls and women with HIV
  • HIV infected children/adolescents presenting with severe symptoms, including respiratory symptoms or other organ involvement, should be investigated for COVID-19 in addition to TB and/or other opportunistic infections as needed.

 

Counseling and support

  • Psychosocial support and coping strategies for children and ALHIV during this pandemic is essential.
  • Provide age-appropriate information and communication about HIV and COVID-19, e.g. when and how to seek care, how to prevent acquisition and transmission of COVID-19 in addition to HIV. (see Information for sexually active adolescents about sexual activities during COVID below)
  • In-person individual or group adherence counseling and support can be modified through phone calls and digital platforms such as social media, apps, websites and text/WhatsApp messages where possible. 
  • Online and other telecommunication options where possible should be used to sustain communication and support for children and ALHIV. 
  • Interactive, virtual, online support platforms, family and household members and networks of young people living with HIV may be instrumental in maintaining safe and age-appropriate social interaction to provide support towards the psychological and mental health well-being of ALH
  • Additional care needs to be taken with tele-communication with adolescents to protect privacy and avoid inadvertent disclosure 
     

Human Rights 

  • Privacy, confidentiality and a rights-based approach must be maintained during this period. 
  • Children and ALHIV should be offered appropriate and equitable access to health services 
  • Pregnant ALHIV and adolescent mothers with HIV, have the right to high-quality care before, during and after childbirth. Antenatal, newborn, postnatal, intrapartum and mental health care, should be protected. They should also have access to contraceptive services or abortion clinics as required.

 

Strict IPC including masking and hand hygiene practices by healthcare providers are required when in contact with children. In the hospital setting, triaging, screening and strict IPC including appropriate masking and hand hygiene practices need to be ensured.

Specific attention needs to be focused on providing equitable care and protection for vulnerable children and adolescents, including; migrants, displaced children, ethnic minorities, children living with disabilities, and those living in urban slums, refugee settlements, and in institutions.

Ensure continued access to crucial programs in an equitable manner

  • Routine immunisation programs must continue as per EPI and country recommendations 
  • Access to maternal newborn health care services observing IPC must be sustained to ensure optimal health outcomes for the mother and her child
  • Management of common diseases must continue through first-level health facilities and home visits by trained workers (IMCI guidelines) (7)
  • Health promotion visits for childcare and early childhood development (ECD) may need to be conducted by tele-consultation and counseling
  • Refer children with severe illness and/or severe acute malnutrition to higher-level facilities with free safe transport 
  • It is vital to be alert to nutritional abnormalities in children
  • Nutritional deficiencies may be due to food insecurity, likely exacerbated during the COVID pandemic
  • Overweight or obese children may be more at risk of developing severe COVID-19 related symptoms 
  • Weight loss or failure to thrive may be more difficult to detect when children do not attend in person for weighing and measurement.
  • Isolation and lockdown put children and young people, particularly girls, at risk of family violence and abuse; HCW need to be alert to signs of this and intervene as needed or refer appropriately
  • HCW also need to be alert to the mental health needs of children likely exacerbated during the pandemic, and should be familiar with basic management strategies or appropriate referral services. 

The 2014–2015 Ebola outbreak was implicated in a surge of negative events including unplanned pregnancies, transactional sex, psychological distress, loss of livelihoods, and school closures that particularly affected adolescents. (8, 9)  

Measures to mitigate the COVID-19 pandemic put women including young women at risk of intimate partner violence and other forms of gender based violence (GBV) due to increased tensions in the household. They may also have decreased access to SRH services.

 

This plays an important role in reaching youth, although services may be altered because of the risk of COVID-19 transmission. Novel methods of providing information and support to adolescents must be established; 

  • Individual or group adherence counseling may be continued through phone calls and digital platforms such as social media, apps, websites and text/WhatsApp messages where possible
  • Multiple communication methods can be used to help raise awareness of and protection from COVID-19, promote healthy behavior, and share correct information. (misinformation is a serious concern and needs to be pro-actively addressed)
  • Young people should be invited to participate or take a leadership role in efforts to mitigate COVID-19 risks and could provide community outreach
  • Services may be youth-led and youth-directed through community-based and NGOs
  • Provide information on how and whom to reach out to for additional support if feeling unwell or psychologically distressed
  • HCW need to be alert to the mental health needs of adolescents, especially those who are female, in senior high school, or use substances, and should be prepared to manage these or refer appropriately. (10, 11, 12)     
  • Ensure measures are in place to prevent, protect and mitigate the consequences of violence, stigma and discrimination against adolescents and youth, including LGBTQI and those with disabilities during quarantine and self-isolation. 

Adolescent sexual and reproductive health (SRH) and family planning services should be accessible including; (13)

  • Access to menstrual products for girls must be sustained
  • Ensure uninterrupted supplies of male and female condoms and lubricants 
  • Uninterrupted access to modern contraceptive methods for girls, including emergency contraceptive pills, self-administration of injectable contraception and advance supply of oral contraceptive pills. (14) 
  • Sexually transmitted infection (STI) management services should be prioritized for adolescents who require them, including options for self-care and self-testing where available. 
  • Telehealth for counseling and sharing of messages related to selection and use of safe and effective use of contraception and programs should ensure adequate inventory to prevent stock-outs
  • Continue to ensure the availability of PEP and PrEP for patients newly initiating PrEP and patients continuing PrEP use
  • HIV and STI tests are recommended quarterly for people on PrEP
  • Self-test collection kits may be used where available for HIV and STI’s – send to the laboratory with follow up communication
  • If in isolation and no sexual contact, discuss with HCW whether and when to stop PrEP after last contact, and when to restart in anticipation of future intimate encounter
  • Antenatal, intra and post-partum care for all pregnant girls, births and emergency obstetric and newborn care 
  • Safe abortion and post-abortion care including medical abortion 
  • Clinical care for rape survivors – including prevention and treatment for HIV and other STIs. 
  • Care for individuals experiencing intimate partner violence — this should remain available for all, including adolescents.
  • Limit disruptions to gender-affirming treatments for transgender program beneficiaries including hormone replacement therapy and psychosocial support
     

 

 

As schooling may be interrupted in many settings during the pandemic, efforts must continue to promote and provide ongoing access to age-appropriate comprehensive sexuality education (CSE) or family life education (FLE), including about HIV/STIs and their prevention, sexuality and sexual health, sexual and gender-based violence, reproduction and reproductive health, and pregnancy prevention, management and care.

ASHM published harm reduction approaches for people engaging in casual sex during the COVID-19 pandemic, which are important for all ages, including adolescents. (15)  SARS-CoV-2 is transmitted through droplet and airborne mechanisms, and transmission during sexual encounters could be higher with kissing if one partner is infected with COVID-19. Research suggests that SARS-CoV-2 may be present in saliva, semen and faeces, although there is no evidence that transmission occurs sexually, or via the faecal-oral route. Avoiding sex, especially casual sex, outside the home is recommended, although complete abstinence from in-person sexual activity may not be an achievable goal for everyone. If adolescents do have sex with others, they should limit the number of partners or consider sexting rather than in-person encounters. Those unable to take this approach may benefit from risk reduction counselling, which has proven effective in other realms of sexual health. (16)

Epidemiology

  • Children make up a small percentage of cases of COVID-19 (1-5% of all cases). 
  • Most infected children are asymptomatic or mildly symptomatic: critical illness occurs rarely (~1%).
  • Emerging trends indicate a lower infection rate in children, but more data are required to determine this
  • Children appear less likely to transmit disease; family cluster studies show that children were seldom the index case. (19) 
  • SARS-CoV-2 can be detected in faeces but uncertainty remains about whether this represents live transmissible virus or viral debris.

Clinical features

  • In >50% symptomatic children, the most common presenting features are cough and fever.
  • Upper respiratory tract symptoms such as rhinorrhoea and sore throat reportedly occur in 30-40% of patients.
  • Diarrhoea and/or vomiting in up to 10% of cases, sometimes as the sole presenting features.
  • Case series of rashes resembling chilblains, often on feet/toes – referred to as ‘COVID toe’ - have been reported.
  • Comorbidities – 61% in children compared to 92% in adult admissions.
  • Children less likely to require ICU and ventilation than adults (more severe in newborn period than in older children) 
  • Multisystem Inflammatory Syndrome of Children (MIS-C) –hyper inflammatory syndrome resembling Kawasaki disease recently characterized - occurs 2 to 4 weeks after infection with SARS-CoV-2. 
  • Uncommon (2 in 100,000 persons <21 years of age) as compared with SARS-CoV-2 infection diagnosed in persons younger than 21 years of age over the same period (322 in 100,000). 
  • Respiratory involvement is notably absent.
  • A recent case series found that among 27 cases of children with MIS-C, 4 presented with neurological involvement, and all 4 had MRI changes. (20)

Investigations

  • Blood tests somewhat different to adults - lymphocytopaenia was relatively rare in children, and most had normal or sometimes raised lymphocyte counts.
  • Inflammatory markers - CRP and Procalcitonin often raised but only mildly.
  • Slight elevation in liver transaminases appeared to be common.
  • Radiographic features were also different to adults – CXR and CT chest often normal.


WHO case definition of Multisystem Inflammatory Syndrome of Children  

Consider this syndrome in children with features of typical or atypical Kawasaki disease or toxic shock syndrome. 
Children and adolescents 0–19 years of age with fever > 3 days 
AND two of the following: 
a) Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet). 
b) Hypotension or shock. 
c) Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP), 
d) Evidence of coagulopathy (by PT, PTT, elevated d-Dimers). 
e) Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain). 

AND 
Elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin. 
AND 
No other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes. 

Evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19.

Contributors can enter data into the web-based WHO COVID-19 Clinical Data Platform, (https://www.who.int/publications/i/item/WHO-2019-nCoV-MIS_Children_CRF-2020.2)
 which captures all COVID-19 variables listed in the case report forms (CRFs). Using the WHO platform facilitates aggregation, tabulation, and analysis across different settings globally and provides a secure, access-limited, password-protected, electronic database hosted in a secure server at WHO.


 

 

Questions and Answers for Adolescents living with HIV in time of COVID-19 UNICEF ESAR
https://www.unicef.org/southafrica/sites/unicef.org.southafrica/files/2020-04/ESAR-questions-answers-adolescents-living-with-HIV-COVID19-2020.pdf
Youth Against COVID-19, UNFPA
COVID-19 and Children Living with HIV: Preventing widening inequalities, UNICEF
Technical Brief: Sexual and Reproductive Health and Rights: Modern Contraceptives and Other Medical Supply Needs, Including for COVID-19 Prevention, Protection and Response, UNFPA
WHO Guidelines for HIV testing https://www.who.int/publications/i/item/consolidated-guidelines-on-hiv-testing-services-for-a-changing-epidemic

8 Ways Governments Can Support Children Living with HIV During the Pandemic, UNICEF
Podcast: HIV & COVID-19 - What do we know so far?, BMJ Sexually Transmitted Infections (Edwina)
Sustaining Condoms and lubricants during COVID-19 https://www.unaids.org/sites/default/files/media_asset/condoms-lubricants-covid19_en.pdf
Webinar: Designing and Programming for Adolescents Self-Care During Strained ASRH Services https://hcdexchange.org/news-events/webinar-designing-and-programming-adolescents-self-care-during-strained-asrh-services 
Minimal Interventional Service Package (MISP)  - for Reproductive Health in Crisis Situations:
 https://iawg.net/resources/misp-reference 

Interagency Working Group (IAWG) on Reproductive Health in Crises
Chapter 6 of the Field Manual
https://iawgfieldmanual.com/manual/asrh 
Adolescent Sexual Reproductive health Toolkit https://iawg.net/resources/adolescent-sexual-reproductive-health-toolkit-humanitarian-settings#

  1. https://www.unaids.org/en/resources/documents/2017/90-90-90
  2. http://aidsinfo.unaids.org/
  3. https://www.avert.org/professionals/hiv-around-world/asia-pacific/overview
  4. Continuing essential Sexual, Reproductive, Maternal, Neonatal, Child and Adolescent Health services during COVID-19 pandemic Operational guidance for South and South-East Asia and Pacific Regions Practical Considerations 1 May 2020
  5. ASHM Taskforce on BBVs sexual health and COVID Elimination of parent to child transmission of HIV, Syphilis and HBV. https://ashm.org.au/covid-19/regional/elimination-of-parent-to-child-transmission-of-hiv-syphilis-and-hbv/
  6. WHO:  HIV self-testing: key questions, answers and messages for community organizations https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox?projector=1
  7. https://apps.who.int/iris/bitstream/handle/10665/42939/9241546441.pdf?sequence=1
  8. United Nations Population Fund (UNFPA). Rapid Assessment of Ebola Impact on Reproductive Health Services and Service Seeking Behaviour in Sierra Leone. Freetown: UNFPA, 2015 
  9. Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of Response to 2014-2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. Emerg Infect Dis. 2016:22(3):433–441. https://doi.org/10.3201/eid2203.150977 )
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196181/
  11. China: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247496/
  12. Pungpapong G, Kalayasiri R. High prevalence of depression, anxiety and stress among secondary school students during COVID-19 lockdown and social distancing. 19th Annual International Mental Health Conference (Mental Health in the COVID-19 Pandemic), 6-7 August 2020, Bangkok, Thailand. Oral abstract #146. 
  13. Not a luxury: A call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic, The Lancet Global Health
  14. https://www.who.int/reproductivehealth/publications/self-care-interventions/en/
  15. https://ashm.org.au/covid-19/clinical-care/harm-minimisation-approaches-to-casual-sex/
  16. https://www.poz.com/article/new-coronavirus-unlikely-sexually-transmitted-via-semen
  17. https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
  18. Castagnoli R, Votto M, Licari A, et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatr. Published online April 22, 2020. doi:10.1001/jamapediatrics.2020.1467
  19. Klara M. Posfay-Barbe, et al, COVID-19 in Children and the Dynamics of Infection in Families. Pediatrics July 2020, e20201576; DOI: https://doi.org/10.1542/peds.2020-1576
  20. Abdel-Mannan O, Eyre M, Löbel U, et al. Neurologic and Radiographic Findings Associated With COVID-19 Infection in Children. JAMA Neurol. Published online July 01, 2020. doi:10.1001/jamaneurol.2020.2687
  21. https://www.who.int/publications/i/item/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19