• New York State Department of Health. Immunologic considerations in HIV-infected children. New York (NY): New York State Department of Health; 2003 Mar. 20 p. [5 references]

This is the current release of the guideline.

• Human immunodeficiency virus infection
• Immune defects
• Vaccine-preventable diseases:
  • Hepatitis B
  • Diphtheria
  • Tetanus
  • Pertussis
  • Polio
  • Measles
  • Mumps
  • Rubella
  • Haemophilus influenzae type B infections
  • Hepatitis A
  • Pneumococcal infections
  • Influenza
  • Varicella (chickenpox)

Diagnosis
Evaluation
Management
Prevention
Screening
Treatment

Allergy and Immunology
Family Practice
Hematology
Infectious Diseases
Pediatrics
Preventive Medicine

Health Care Providers
Physician Assistants
Physicians
Public Health Departments

To develop guidelines on the laboratory evaluation and management of immune defects in human immunodeficiency virus (HIV)-infected pediatric patients, including the use of antiretroviral and immune-based therapies

Human immunodeficiency virus (HIV)-infected children

1. Antiretroviral therapy
2. Routine immunization of human immunodeficiency virus (HIV)-infected children with the following vaccines:
   • Hepatitis B
   • Diphtheria, tetanus, acellular pertussis
   • Inactivated polio
   • Measles, mumps, rubella
   • Haemophilus influenzae type B
   • Hepatitis A
   • Pneumococcal, polysaccharide, and conjugate
   • Influenza
   • Varicella
3. Laboratory evaluations with quantitative assessment of the cellular immune system, including lymphocyte immunophenotyping, to determine absolute numbers and percentages of CD4 and CD8 T lymphocyte subsets

Not stated

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not applicable

Expert Consensus

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3 to 4 times per year, and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Antiretroviral Therapy and The Immune System

For specific clinical recommendations, the clinician should refer to Chapter 4: Pediatric Antiretroviral Therapy.

Immunization of Human Immunodeficiency Virus (HIV)-Infected Children

Immunizations to prevent infections should be used when available and safe (see Table 1 below and in the original guideline document).

Immunologic Laboratory Evaluation of HIV-Infected Children

A baseline evaluation should be completed and should include quantitative assessment of the cellular immune system, including lymphocyte immunophenotyping, to determine absolute numbers and percentages of CD4 and CD8 T lymphocyte subsets.

Lymphocyte subsets should be obtained at baseline (preferably in replicate), and 1 to 2 months after initiation of a new antiretroviral (ARV) regimen as a measure of response to treatment. They should subsequently be repeated every 3 to 4 months to make sure immune function is being maintained, or more frequently in children with clinical deterioration or rapid decline in CD4 count.

Table 1: Routine Immunization for HIV-Infected Children

Vaccine: Use and Precautions

• Hepatitis B: YES
• Diphtheria, tetanus, acellular pertussis: YES
• Inactivated polio: YES; do not use oral polio vaccine; inactivated vaccine for household contacts
• Measles, mumps, rubella: YES except in severely immunocompromised children [i.e., children in CD4 Immunologic Category 3 (see Table 2 below)]
• Haemophilus influenzae type B: YES
• Hepatitis A: CONSIDER, especially in children with hepatitis B and C and other liver dysfunction, and in travelers
• Pneumococcal, polysaccharide, and conjugate: YES
• Influenza: YES
• Varicella: YES, ONLY to children who are asymptomatic and in CD4 Immunologic Category 1 (see Table 2 below); OFFER to uninfected, nonimmune household contacts

Table 2. Immunologic Categories for HIV-Infected Children Based on Age-Specific CD4 T-Lymphocyte Counts and Percentage of Total Lymphocytes

Immunologic category

No evidence of suppression

Age and cells/mm³ (%)*

• <12 months: ≥1,500 (>25)
• 1-5 years: ≥1,000 (>25)
• 6-12 years: ≥500 (>25)

Evidence of moderate suppression

Age and cells/mm³ (%)*

• <12 months: 750-1,499 (15-24)
• 1-5 years: 500-999 (15-24)
• 6-12 years: 200-499 (15-24)

Severe suppression

Age and cells/mm³ (%)*

• <12 months: <750 (<15)
• 1-5 years: <500 (<15)
• 6-12 years: <200 (<15)

* Percentage of total lymphocytes.

None provided

The type of evidence supporting the recommendations is not stated.

Appropriate evaluation and management of immune defects in HIV-infected children

Not stated

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening, or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience
• Define target audience (providers, consumers, support service providers)
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)?
• Define implementation methods
  • What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)?
• Determine appropriate implementation processes
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)?
  • What necessary processes are external to the organization (e.g., meetings with external groups, conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate
  • Did the processes and strategies work? Were the guidelines implemented?
  • What could be improved in future endeavors?

Living with Illness
Staying Healthy

Effectiveness

• New York State Department of Health. Immunologic considerations in HIV-infected children. New York (NY): New York State Department of Health; 2003 Mar. 20 p. [5 references]

Not applicable: The guideline was not adapted from another source.

2003 Mar

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Committee for the Care of Children and Adolescents with HIV Infection

Committee Chair: Joseph S. Cervia, MD, Director, The Comprehensive HIV Care and Research Center, Long Island Jewish Medical Center

Committee Vice Chair: Jeffrey M. Birnbaum, MD, MPH, Director, HEAT Program, Kings County Hospital

Committee Members: Elaine Abrams, MD, Director, Family Care Center, Department of Pediatrics, Harlem Hospital Center; Saroj Bakshi, MD, Chief, Division of Pediatric Infectious Diseases, Bronx-Lebanon Hospital Center; Howard J. Balbi, MD, Director, Pediatric Infectious Diseases and Pediatric AIDS Program, Nassau County Medical Center; Coleen K. Cunningham, MD, Associate Professor of Pediatrics, SUNY Upstate Medical University; Samuel Grubman, MD, Chief, Allergy and Immunology, Saint Vincents Catholic Medical Centers, St. Vincent's Manhattan; Sharon Nachman, MD, Chief, Pediatric Infectious Diseases, Associate Professor of Pediatrics, SUNY at Stony Brook. Department of Pediatrics; Catherine J. Painter, MD, PhD, Assistant Professor of Clinical Pediatrics, College of Physicians and Surgeons, Columbia University, Medical Director, Incarnation Children's Center; Vicki Peters, MD, Coordinator, Pediatric HIV Special Projects, Office of AIDS Surveillance, New York City Department of Health; Roberto Posada, MD, Assistant Professor of Pediatrics, Division of Pediatric Infectious Diseases, Director, Pediatric HIV Program, Mount Sinai School of Medicine; Barbara Warren, BSN, MPH, PNP, Assistant Bureau Director, Bureau of HIV Ambulatory Care Services, AIDS Institute, New York State Department of Health; Geoffrey A. Weinberg, MD, Director, Pediatric HIV Program, Associate Professor of Pediatrics, Department of Pediatrics, University of Rochester School of Medicine and Dentistry; Ed Handelsman, MD, Assistant Professor of Pediatrics, SUNY Health Sciences Center at Downstate, Assistant Medical Director of Pediatrics, Office of the Medical Director, AIDS Institute

Not stated

This is the current release of the guideline.

None available

This summary was prepared by ECRI on January 21, 2004.