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
Counseling and support
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
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;
Adolescent sexual and reproductive health (SRH) and family planning services should be accessible including; (13)
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)
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).
Elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin.
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
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:
Interagency Working Group (IAWG) on Reproductive Health in Crises
Chapter 6 of the Field Manual
Adolescent Sexual Reproductive health Toolkit https://iawg.net/resources/adolescent-sexual-reproductive-health-toolkit-humanitarian-settings#