| HOME | HELP | E-MAIL ALERTS | SEARCH |
|
| ||||||||||||||||||||||||||||||||||||||||||||||||
PEDIATRICS Vol. 106 No. 1 July 2000, pp. 149-153
 |
ABSTRACT |
|---|
Top
Abstract
Conclusion
Recommendation
References
|
|---|
As a consequence of the expanding human immunodeficiency virus (HIV) epidemic and major advances in medical management of HIV-exposed and HIV-infected persons, revised recommendations are provided for HIV testing of infants, children, and adolescents in foster care. Updated recommendations also are provided for the care of HIV-exposed and HIV-infected persons who are in foster care.
An estimated 500 000 children and adolescents in the
United States are in foster care.1 Entrance to the foster
care system may occur as a consequence of parental substance abuse, neglect, physical abuse, sexual abuse, or loss of biologic parent(s) resulting from abandonment, incarceration, disability, or death. As
many as 78% of children in foster care have a parent with a history of
substance abuse, and as many as 94% of infants in foster care are born
to women who abuse substances.2 The number of women with
human immunodeficiency virus (HIV) infection has increased
substantially, and most of these women are of childbearing age.
Approximately 7000 births occur annually in the United States to
HIV-infected women, and most of these women have been infected through
heterosexual contact or as a consequence of drug use.3 Seroprevalence of HIV infection in pregnancy nationwide is 1.7 per 1000 pregnant women, and in New York, where all newborns are tested for the
HIV antibody, seroprevalence is 4 per 1000 pregnant women.4 An inner-city study found that newborns placed in
foster care at the time of hospital discharge were 8 times more likely
to have been born to HIV-infected women than were newborns discharged
to the care of their mothers.5
In addition to the increased risk of perinatally acquired HIV infection
for those in foster care, children and adolescents in foster care may
have been sexually abused, placing them at risk for acquisition of HIV
infection. Adolescents who use drugs or are sexually active are also at
risk for acquisition of HIV infection, and adolescent risky behavior
may precede placement in foster care or may occur while in foster care.
Although advances in antiretroviral therapy for adults have helped
decrease the projections of 80 000 to 150 000 children and
adolescents orphaned in the United States by the death of their mother
to acquired immunodeficiency syndrome by the year 2000,6,7 many HIV-infected women will still not survive to raise their offspring
to adulthood, and their children may enter the foster care system as a
consequence of maternal disability or death. Data from the Pediatric
Spectrum of Disease project revealed that 45% of children born to
HIV-infected women resided with a primary caregiver who was not the
biological parent.8
Advances in the management of HIV infection include prenatal and
postnatal administration of zidovudine to reduce the risk of infection
of the infant, recommendations for initiation of Pneumocystis
carinii pneumonia prophylaxis by 6 weeks of age for all infants
born to HIV-infected women, variations in immunization recommendations
for infected persons and infants at risk of infection, and
recommendations for consideration of early and aggressive combination
antiretroviral therapy for those who are infected.9-11 The American Academy of Pediatrics (AAP) therefore issues
recommendations in accordance with these recent advances to address the
identification and care of HIV-exposed and HIV-infected infants,
children, and adolescents in foster care.
The AAP, the American College of Obstetricians and Gynecologists,
and the US Public Health Service have recommended that all pregnant
women in the United States receive counseling about HIV infection and
the benefits to the mother and her infant of knowing her serologic
status and that all pregnant women should undergo routine testing for
HIV.12-14 The Institute of Medicine recently recommended
a nationwide policy of HIV testing during pregnancy (with right of
refusal).4 In addition, if the mother's HIV status was
not determined during pregnancy, the AAP recommends that, after birth
of the infant, the pediatrician discuss with the mother the benefits to
the infant of knowing the mother's serologic status and recommend
testing at that time.12
The management of the HIV-exposed infant is complex and includes
continuation of zidovudine prophylaxis during the first 6 weeks after
birth, initiation of prophylaxis for Pneumocystis carinii
pneumonia by 6 weeks of age in all infants born to HIV-infected women,
monitoring of hematologic and immunologic parameters, specific laboratory testing to determine HIV infection status (DNA polymerase chain reaction [PCR] or viral culture), and variations in
immunization recommendations.9 Advances in laboratory
diagnosis (DNA PCR and viral culture for HIV) enable physicians to
determine infant infection status by 28 days of age in as many as 96%
of infants born to HIV-infected women.15,16 Published data
suggest that RNA PCR may prove useful for early identification of
infant infection status.17,18 Prompt identification of
infected infants permits early initiation of aggressive antiretroviral therapy with the potential to prevent the rapid progression of illness
seen in some HIV-infected infants.
Thus, to provide appropriate medical care for the infant, it is
necessary that foster care agencies obtain information about HIV
exposure status, if known, for infants placed in foster care. If the
maternal serologic status is unknown, the HIV exposure status of
infants in foster care, including infants placed in foster care at
nursery discharge and infants placed in foster care who are 1 year of
age or younger, should be determined by testing the infants for HIV
antibody. When the authority to consent to medical care has been
transferred from the biological parents to a foster care agency, and
the HIV-exposure status of the infant is unknown, the agency should
provide consent for HIV testing of the infant and have an established
mechanism to facilitate testing and to allow exchange of confidential
information with appropriate persons (eg, physician, nurse, caseworker
coordinating care for the foster child, biological parents, and the
foster parents). Occasionally, legal restrictions may prevent testing of the infant in foster care without maternal consent. In such cases,
the physician may need to consult with the foster care agency and legal
authorities. Efforts should be made to educate the biological mother,
if available, of the potential benefits to herself and to her infant of
knowing maternal serologic status. Communication of information about
any positive test results to the biological parent(s) or the foster
parent(s) should occur in a health care setting with appropriate social
service support available at the time of the meeting. Infants who are
identified as HIV-exposed (born to an HIV-infected woman) should be
managed in accordance with established guidelines.9
HIV-infected children may remain asymptomatic for years or have
mild nonspecific symptoms (anemia, poor growth, developmental delay)
that are not recognized as secondary to HIV infection. In a cohort of
HIV-infected children, 32 (17.7%) of 181 HIV-infected children were
first diagnosed at 4 years of age or older.19 In another
cohort of 42 perinatally infected long-term survivors between the ages
of 9 and 15 years, 36 had no symptoms until after the age of 4 years.20 Two children with perinatally acquired HIV
infection have remained asymptomatic for almost 13 years.21,22 In addition, transfusion-acquired HIV
infection may be associated with an asymptomatic or a minimally symptomatic phase of illness, thus delaying diagnosis of HIV
infection.23 Because of the increasing recognition of HIV
infection among older children, foster care agencies should create
policies to facilitate testing of older children. Testing for HIV
should be performed for all children in foster care with symptoms or
physical findings compatible with HIV infection and for all children
with a sibling or parent who is HIV-infected. Because factors that lead
to placement of children in foster care frequently are associated with
an increased risk of HIV infection in the child and parents,
determining the status of all older children who are in the foster care
system whose maternal serologic status is unknown may be prudent.
Diagnosis of HIV infection is made in a child 18 months of age or older
when antibody testing by enzyme-linked immunosorbent assay and the
Western blot technique is positive or when the child meets diagnostic
criteria for the younger infant (positive HIV-specific diagnostic
assays, ie, DNA PCR or viral culture on 2 separate blood specimens from
the infant). Results of tests should be provided by the child's
physician to foster parents, biological parents (if possible), foster
care agency, and the child (if old enough to comprehend and if
disclosure is appropriate to the developmental level of the
child).24
Annually, more than 125 000 children and adolescents are sexually
abused in the United States, and sexual abuse has been the mode of
acquisition of HIV infection in at least 26 children younger than 13 years.25 As part of sexual abuse evaluation, laboratory
testing when performed should include HIV testing. Testing for HIV
should be performed at the time of the initial assessment with repeated
serologic testing at 6 weeks, 3 months, and 6 months after the incident
of sexual abuse for children whose initial test results are
negative.26 Testing also should be repeated if symptoms
suggestive of HIV infection occur. Foster care agencies should develop
mechanisms to ensure that initial and follow-up serologic tests are
obtained when indicated.
HIV-infected adolescents may be unaware of their infection status.
Adolescents in foster care, just as those who are not in the foster
care system, may acquire HIV infection as a consequence of their own
sexual activity or illicit drug use or may have been infected by
previous sexual abuse or, rarely, by perinatal transmission. Adolescents who have been victims of sexual abuse are more likely to
engage subsequently in sexual behavior that may place them at increased
risk for acquiring HIV infection and other sexually transmitted
diseases.27 Homeless adolescents frequently engage in
prostitution in exchange for money, food, or shelter, and a period of
homelessness may occur before an adolescent is placed in foster care.
In a New York City shelter for homeless adolescents, 6% of the
residents were seropositive.28 Intravenous drug use has
long been recognized as a risk factor for HIV infection. Cocaine use
also has been reported as a risk factor for HIV infection because it
may involve the exchange of sex for drugs or engaging in risky sexual
behavior while under the influence of the
drug.29,30 It is important, though, to recognize
that the epidemiology of HIV infection is changing and that there is an
increased incidence of HIV transmission in the adolescent population
through homosexual and heterosexual contact.
For adolescents in foster care (as for adolescents who are not in
foster care), HIV testing should be recommended for those who have
symptoms or physical findings suggestive of HIV infection and for those
who have any of the following known risk factors for HIV infection: a
sibling, or parent who is HIV infected, a current or past sexual
partner who is HIV-infected or at increased risk of HIV infection;
receipt of a blood transfusion before 1985; a history of sexual abuse;
a diagnosis of a sexually transmitted disease; or a history of illicit
substance use or abuse. In addition, HIV testing should be considered
for all adolescents in foster care who are sexually active or have a
history of sexual activity and for those whose medical history and
family history are unavailable or inadequate for assessment of the
aforementioned risk factors. Evaluation should be performed in the
context of provision of comprehensive adolescent health care, and all
adolescents should receive education and counseling from a health care
professional about prevention of transmission of HIV infection.
All states allow adolescents to consent to confidential evaluation and
treatment for sexually transmitted diseases.31 In some
states, adolescents may legally consent to confidential HIV
testing and treatment. Testing of the adolescent should be performed with assent of the adolescent.32 If testing of
the adolescent is performed in association with evaluation for sexual
abuse or because of high-risk behavior, foster care agencies and
physicians providing such care should ensure that appropriate follow-up
testing is obtained. Communication of positive test results to the
adolescent should occur in the health care setting. State regulations
may require consent of the adolescent for disclosure of test results to
other individuals or agencies participating in the adolescent's care.
Provision of Medical Care
Foster care agencies should periodically review, with physician
guidance, the agency policies pertaining to the care of HIV-exposed infants and HIV-infected infants, children, and adolescents. In addition, periodic review should occur of policies related to acquisition and communication of medical information and other confidential information for those in foster care, including infants placed in foster care at the time of hospital discharge. It is the
responsibility of the discharging physician to provide records, including confidential HIV-related information, to the physician designated to assume care or to the agency for provision to the physician who will assume care. Similarly, when a child or adolescent initially is placed in foster care, the agency should contact the
physician providing care to obtain complete medical records and
determine if there are acute or chronic medical problems that require
medical follow-up, the immunization status, and whether the person is
taking medication.
Maintenance of a "medical home" is important in the care of all
foster children and is particularly beneficial for those with chronic
health problems, such as HIV infection.33 Foster care
agencies should ensure, in the event of a change in physicians, that
complete medical and immunization records are transferred to the new
physician. Agencies providing foster care should minimize or eliminate
barriers to sharing confidential information among counselors, mental
health professionals, caseworkers, and the physician providing care to
the child or adolescent. Comprehensive care for HIV-exposed infants and
HIV-infected infants, children, and adolescents requires coordination
of care among multiple health care professionals and social service
agencies. Use of the "health passport" (a booklet summarizing
medical information, including illnesses, medications, immunizations,
family history, and names of current and previous physicians) for
children in foster care can assist in communication of information if
the child changes physicians or is placed in a new foster
home.34
With the increasing identification of HIV infection among pregnant
women, there also has been increasing use of prophylactic zidovudine to
reduce the risk of perinatal HIV infection.35 This regimen
is considered safe for mother and child.36 However, the
long-term consequences of in utero exposure to zidovudine and other
antiretroviral agents are unknown. It is critical that information
about in utero exposure to antiretroviral drugs be included in the
medical records of infants born to HIV-infected women. All such
infants, whether infected or uninfected, should receive long-term
follow-up.
Owing to rapid advances in management of HIV infection, involvement in
clinical trials may provide benefit to HIV-exposed infants and
HIV-infected infants, children, and adolescents in foster care. In
addition, clinical trials that do not involve a therapeutic agent but
provide long-term follow-up of HIV-exposed and HIV-infected children
and adolescents provide important benefits. Agencies providing foster
care should have established procedures for access to studies and to
clinical trials.
Foster Parent Education
Foster care agencies should provide education about HIV to all
foster parents as part of their initial training. Such education should
be updated periodically and should include infection control guidelines
for use in the home setting.37 Foster parents should be
aware that there may be HIV-infected infants, children, and adolescents
in foster care whose HIV status is unknown. Foster parents providing
care to HIV-exposed infants should be educated about all issues in the
management of the HIV-exposed infant that usually are discussed with
the biological parent.9
Because provision of medical care for HIV-exposed infants and
HIV-infected infants, children, and adolescents is complex and requires
frequent office visits, foster care agencies should develop procedures
to ensure that those in foster care are seen at intervals deemed
appropriate by the physician. If an HIV-exposed or HIV-infected child
in foster care is transferred to a different foster home, the physician
should be notified promptly (preferably before the transfer) to enable
the physician to adequately inform the new foster parents about the
child's health care needs, provide ongoing medication, and assist with
additional education of new foster parents about HIV infection.
Permanency Planning
Although many children born to HIV-infected women are already in
foster care or in the care of relatives outside the foster care system
before the onset of debilitating complications in the mother or
maternal death, infected women may not have made plans for provision of
care for their children. In addition to determining who will provide
care, it is necessary that provisions be made for long-term access to
health care (physical and psychological) for HIV-infected offspring and
for uninfected offspring. Permanency planning is a coordinated effort
involving health care professionals, mental health professionals,
social workers, foster care agencies, legal personnel, the biological
family, and the designated "second family."38
These recommendations about HIV testing of infants, children, and
adolescents in foster care and for enhanced coordination of care by
physicians and foster care agencies are made to provide maximal
opportunity for those in foster care to benefit from the dramatic
medical advances in the care of HIV-exposed and HIV-infected infants,
children, and adolescents.
HIV TESTING OF A CHILD IN FOSTER CARE WHO IS 1 YEAR OF AGE OR
YOUNGER
HIV TESTING OF CHILDREN IN FOSTER CARE WHO ARE OLDER THAN 1 YEAR
HIV TESTING OF SEXUALLY ABUSED CHILDREN
HIV TESTING OF ADOLESCENTS IN FOSTER CARE
ISSUES RELATED TO THE CARE OF HIV-EXPOSED AND HIV-INFECTED INFANTS,
CHILDREN, AND ADOLESCENTS IN FOSTER CARE
CONCLUSION
Top
Abstract
Conclusion
Recommendation
References
RECOMMENDATIONS
Top
Abstract
Conclusion
Recommendation
References
Testing for HIV also should be considered for all foster children whose maternal serologic status is unknown.
3. Testing for HIV (with assent of the adolescent) is recommended for all adolescents in foster care who have:
Testing for HIV also should be considered for all adolescents in foster care who are sexually active or have a history of sexual activity and for those whose medical history and family history are unavailable or inadequate for assessment of the aforementioned risk factors.
4. Physicians and foster care agencies should take joint responsibility to ensure appropriate exchange of complete medical records and confidential information necessary for the management of infants, children, and adolescents in foster care.
5. All foster parents should receive education about HIV infection, and the content of such education should be updated regularly.
6. All foster parents should be informed of the HIV exposure or infection status of infants and children in their care. Disclosure of adolescent HIV status should legally require the consent of the adolescent.
7. Foster care agencies should have established procedures to provide access for HIV-infected and HIV-exposed foster children to treatment-related and non-treatment-related clinical trials.
COMMITTEE ON PEDIATRIC AIDS, 1999-2000
Catherine M. Wilfert, MD, Chairperson
Mark W. Kline, MD, Chairperson-elect
Donna Futterman, MD
Peter L. Havens, MD
Susan King, MD
Lynne M. Mofenson, MD
Gwendolyn B. Scott, MD
Diane W. Wara, MD
Patricia N. Whitley-Williams, MD
LIAISON
Mary Lou Lindegren, MD
Centers for Disease Control and Prevention
CONSULTANT
Donna T. Beck, MD
COMMITTEE ON PEDIATRIC AIDS, 1995-1999
Staff
Eileen Casey, MS
| |
FOOTNOTES |
|---|
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
| |
ABBREVIATIONS |
|---|
HIV, human immunodeficiency virus; AAP, American Academy of Pediatrics; PCR, polymerase chain reaction.
| |
REFERENCES |
|---|
|
Top
Abstract
Conclusion
Recommendation
References
|
|---|
This article has been cited by other articles:
 |
|
 |
|
  S. M. King, Committee on Pediatric AIDS, and Canadian Paediatric Society, Infectious Diseases a Evaluation and Treatment of the Human Immunodeficiency Virus-1--Exposed Infant Pediatrics, August 1, 2004; 114(2): 497 - 505. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Human Immunodeficiency Virus Infection Red Book, January 1, 2003; 2003(1): 360 - 382. [Full Text]
|
|
|
|
|
|
M. D. Simms, H. Dubowitz, and M. A. Szilagyi Health Care Needs of Children in the Foster Care System Pediatrics, October 1, 2000; 106(4): 909 - 918. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | E-MAIL ALERTS | SEARCH |
