pediatric hiv/aids

Pediatric HIV/AIDS

Courtesy of:

International Center for AIDS Care and Treatment Programs

Columbia University

Mailman School of Public Health

Overview

3

Learning Objectives: Overview and Challenges Describe the scope of the pediatric HIV/AIDS

epidemic in Sub-Saharan Africa and Ethiopia List the special challenges in the care of children

with HIV/AIDS Discuss ways to overcome these challenges

4

Historical Perspective of Pediatric HIV: Sub-Saharan Africa 1983-1985 the first cases of pediatric HIV were

first observed in Rwanda, the Democratic Republic of Congo, and Uganda

Mid 1980’s longitudinal cohort studies started in East Africa (Kigali, Kampala, Kinshasha, Nairobi) to study maternal to child transmission and the natural history of HIV-exposed and infected children

In 1988 the first specialist clinic started in Uganda

Western & Central Europe6 200

[4 900 – 7 900]

North Africa & Middle East24 000

[7 100 – 82 000]

Sub-Saharan Africa1.9 million[1.7 – 2.3 million]

Eastern Europe & Central Asia8 800[7 100 – 13 000]

East Asia9 400[3 300 – 27 000]

South & South-East Asia 170 000 [95 000 – 320 000]

Oceania700

[< 2 500]

North America11 000

[5 600 – 17 300]

Caribbean23 000

[12 000 – 49 000]

Latin America26 000

[21 000 – 43 000]

Estimated Number of Children <15 Years Living with HIV/AIDS at the End of 2005

Sub-Saharan Africa

2.3 million[2..1-2.8 million]

Estimated Number of Children (<15 years) Newly Infected with HIV During 2005

Western & Central Europe< 100

North Africa & Middle East9 100

[2 800 – 30 000]

Sub-Saharan Africa

560 000[500 000 – 650 000]

Eastern Europe & Central Asia1 800[1 200 – 3 700]

East Asia4 100[1 500 – 11 000]

South & South-East Asia

51 000[30 000 – 95 000]

Oceania< 300[< 1 000]

North America< 100

Caribbean6 100

[3 100 – 13 000]

Latin America6 800

[5 400 – 11 000]

7

Children Born with HIV

In 2003, there were an estimated 128,000 pregnancies among HIV-infected women in Ethiopia

At least 35,000 infants were born with HIV

8

Pediatric HIV/AIDS in Ethiopia

More than 122,00 children under the age of 15 are living with HIV/AIDS in Ethiopia

63,000 are in immediate need of ART Only 1200 are on ART ~1.9% Over 29,000 people receiving ART in Ethiopia,

however only 4% are children

9

BARRIERS TO CARE

Why is care for infants and children difficult?

Technical barriers in low-resource settings

Disease progression is especially rapid in children

Marginal political/community commitment to a pediatric agenda

10

BARRIERS TO CARE: Technical Barriers Diagnostic challenges

Identification, virologic testing of infants <18 months, stigma, consent, etc)

Complexity of ART administrationProcurement of pediatric formulations Weight-based dosingPediatric adherence

Infrastructure & human resource requirementsPMTCT follow upSystems for chronic care (appointments, medical records,

community outreach)Training

11

Success Stories

Dramatic improvements in morbidity and mortality have been seen in high resource settings secondary to:Accessible pediatric health servicesWidespread use of OI prophylaxis (cotrimoxazole)Access to antiretroviral therapySuccessful perinatal prevention

Care and treatment is also feasible in resource limited settings

12

Response to ART among children in the MTCT-Plus Initiative

Mean increase in CD4 of 431 cells/6 mo

Mean increase in CD4% of 10.5%

In age-stratified analysis, response was best in children in whom ART was initiated at < 12 mo of age

-20 0 20 40 60 80 100 120

Time since ART initiation (weeks)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

CD

4+ p

erce

nt

(%)

Abrams et al. IAS 2005, abstract # MoPe11.6C28

13

Pediatric Care and Treatment

Maximize interventions for PMTCT

Enhance care and treatment for HIV-infected and HIV-exposed infants

Engage women and their families in comprehensive care and treatment

14

Increase availability of infant diagnostics

Enhance case finding and referral

Ensure follow up and comprehensive care and treatment

Increase availability of and access to pediatric ART

Pediatric Care and Treatment (2)

Care of the HIV-Exposed Infant

16

Learning Objectives: Care of the HIV-Exposed Infant Understand the distinction between HIV-

exposed and HIV-infected infants Recognize the goals of care for HIV-exposed

infants Understand routine care procedures for HIV-

exposed infants

17

Challenges to Care

Disease Transmission: antepartum, intrapartum, or postpartum (through breast feeding)

Testing: All exposed infants (infected and non-infected) will test antibody positive during the first few months of life

Exclusion: While the child with HIV infection can often be identified during the first months of life, HIV infection often cannot be excluded until after 1 year of age, particularly in breast fed babies

18

Challenges to Care (2)

Disease Progression: rapid progression in pediatric cases and often requires treatment before a positive diagnosis can be confirmed

Opportunistic Infections: HIV-infected infants are susceptible PCP, TB, and bacterial infections that are associated with high rates of infant mortality

19

Clinical Objectives

Close monitoring of HIV-exposed infantsfor rapid disease progression and failing health status

Use of prophylaxis in HIV-exposed infantsto prevent opportunistic infections

Early identification and treatment of HIV-infected infants

20

Background: Pediatric HIV Disease

Infancy and early childhood is a time of rapid HIV disease progression

Most children die before a diagnosis of HIV is made Common causes of morbidity and mortality in children

Growth failureTuberculosisPCPHIV encephalopathyBacterial infections/pneumonia

21

Components of Clinical Care for the HIV-Exposed Infant History (birth, interim history, and parental

concerns) Physical exam Growth and nutrition evaluation Developmental assessment Cotrimoxazole preventative therapy Determination & evaluation of infection status Assessment and plan

22

Clinical Care: History

Birth-Identify children at higher risk of transmission/infection and higher risk of rapid progression

Parents should be given the opportunity to communicate anxieties and problems as they will be the first to recognize them

At each visit ask: Has the child been ill? How is the child eating? Any

new accomplishments? Has anyone in the household been diagnosed or developed symptoms of tuberculosis? Any new medications?

23

Clinical Care: Physical Exam

Monitor growth rate: Infected infants generally grow more slowly than

uninfected infants. Growth can be the most sensitive clinical indication of

HIV infection in an infant/young child and needs to be monitored closely for all exposed infants

Monitor disease progression: Infected infants have a high frequency of HIV related

morbidities due to rapid disease progression. Example: fever, oral thrush, skin rashes, hepatomegaly, splenomegaly, lymphadenopathy, weakness, muscle wasting, encephalopathy, etc.

24

Clinical Care: Growth and Nutrition

Growth Chart: What is it? Growth data collected from large numbers of children

in a particular population.Normative data on weight, height and head

circumference by age and sex Why use it?

Easy and systematic way to follow changes in growth over time for an individual child

Easy to plot measurements at regular intervals• Monthly for all infants• Quarterly for older HIV-infected children

25

Growth Chart/Curve

Use WHO growth curves or CDC growth curves

The choice of growth chart is less important than following the growth of an individual child along their own curve on a chart

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WHO Growth Curves

WHO growth curves areAge and gender specificExtend from birth to 5 years

• Weight for age: boys and girls

• Height/length for age: boys and girls

• Weight for height/length: boys and girls

• BMI for age: boys and girls

Use WHO Growth Curves to monitor growth of boys and girls, birth to 5 years

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WHO Child Growth Curves

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CDC Growth Curves

CDC growth curves areAge and gender specificExtend from birth to 20 years

• Weight for age: boys and girls• Height/length for age: boys and girls• Head circumference for age: boys and girls• Weight for height/length: boys and girls• BMI for age: boys and girls

Use CDC Growth Curves to monitor: Growth of boys and girls, > 6 yearsHead circumference for boys and girls < 3 years

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How to Use and Interpret a Growth Curve Measure and weigh child using same

methodology at each visitUse a GROWTH CURVE for weight, height, and head

circumference plotted EVERY MONTH Using age and sex appropriate charts, plot

measurement (weight, height, head circumference) on the vertical against age on the horizontal axis

Compare growth point with previous points Assess growth percentile

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Weight for Age

The child is in the 15th percentile of weight for age

He is 4 months old

The

chi

ld w

eigh

s 6k

g

31

95

90

75

50

25

10

5

Age is 3 months

The head circumference is below the 5th percentile for ageThis child is microcephalic

Hea

d c

ircu

mfe

ren

ce i

s 38

cm

Head circumference for age

32

Clinical Care: Growth and Nutrition

Nutrition: Assess mode of feeding frequency (duration or ounces)adequacy of supplybowel habits, reported problems

Infant feeding practices

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Infant Feeding Practices

Mixed feeding may increase the infant’s chance of becoming HIV infected during the period of breastfeeding

For HIV infected mothers choosing to breastfeed, WHO recommends exclusive breastfeeding for 6 months

34

Breast Feeding

Advantages Promotes closeness between

mother and infant Protective maternal antibodies Does not depend on

availability of formula or clean water

Societal norm Exclusive breast feeding may

not increase the risk of MTCT Does not impact maternal

health status

Disadvantages Risk of HIV transmission to the

infant If maternal health is poor,

maternal milk may not be complete in nutrients

35

Formula Feeding

Advantages Decreased risk of PMTCT Baby can be fed by other

family members Feeding from a bottle or

cup requires less work for the infant

Nutritionally complete (doesn’t depend on mother’s health)

Disadvantages Costly and not readily

available in many settings Not societal norm in

many settings No maternal antibodies Need clean water, clean

supplies Need supplies on hand

when not at home

36

Summary: Infant Feeding

Choosing to breast feed or formula feed is complex:Personal preference of woman/familyLocal community normsAvailability of supplies (formula, water)

Counseling should be provided re: risks and benefits Women should be supported in their decisions about

feeding choices Infant feeding should be discussed at each visit for

mother and childAssure accurate history of intakeAssess problems and concerns

37

Clinical Care: Developmental Assessment

Delayed/abnormal development or loss of milestones may be the first sign of HIV infection in infants that raise concerns

Abnormal development can be caused by other factors

Infants are at high risk for HIV encephalopathy

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Clinical Care: Developmental Assessment (2) A developmental assessment that includes the

following should be conducted at each visit: Cognitive, motor, language, and social skillsDiscuss the infant’s milestones Verify appropriate development for ageUse a developmental check list or observe the infant

during the examination

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Clinical Care: Developmental Assessment (3) Developmental Checklist may include:

1 month: raises head, crawling movement, alerts to sound

2 months: head midline, lifts chest off table, smiles socially

4 months: rolls front to back, laughs6 months: sits unsupported, babbles9 months: pulls to stand, says “mama”12 months: walks alone, two words

40

Clinical Care: Cotrimoxazole Preventive Therapy HIV infected infants are at high risk for acquiring pneumocystis

jiroveci pneumonia (PCP), a rapidly progressive pneumonia Severe and rapidly progressive pneumonia

Tachypnea Hypoxia Diffuse interstitial pneumonitis High risk of death

Occurs early, often before child is identified as HIV-infected Peak incidence is between 3-6 months

Diagnosis difficult and invasive measures are often necessary (tracheal aspirate, induced sputum, BAL)

Risk can be reduced with routine use of cotrimoxazole

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The most common OI in children in the US was PCP with the peak incidence is at 3-6 months of life

Can also occur in older children with severe immune compromise

Introduction of routine prophylaxis for all HIV-exposed, coupled with effective perinatal prevention resulted in a drastic reduction in PCP in the US

Clinical Care: Cotrimoxazole Preventive Therapy (2)

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Diagnosis of PCP in HIV-Infected Children with Respiratory Disease

0

10

20

30

40

50

60

Capetown Bangkok Soweto Lusaka

% P

CP

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Clinical Care: Cotrimoxazole Preventive Therapy (3) Given to all HIV-exposed and infected infants 1-

12 months PCP prophylaxis for HIV-exposed infants

Until the child is no longer breast-feeding and is determined to be uninfected or

After two negative virologic tests, with one ≥ 4 months, in clinically well, exclusively formula-fed infants

44

Trimethoprim/sulfamethoxazoleCTX/SMZ, Cotrimoxazole, Septrim®, Bactrim®

weight in kilograms 8mg/ml suspension(daily dose in milliliters)

single-strength tablet (80 mg TMP/400 mg SMZ)

3 – 4.9 kg 2 ml daily

5 – 6.9 kg 3 ml daily

7 – 9.9 kg 4 ml daily ½ single-strength tab daily

10 – 11.9 kg 5 ml daily ½ single-strength tab daily

12 – 14.9 kg 7 ml daily 1 single-strength tab daily




25 – 29.9 kg 14 ml daily 2 single-strength tabs* daily

30 – 34.9 kg 17 ml daily 2 single-strength tabs* daily

35 – 40 kg 20 ml daily 2 single-strength tabs* daily

CPT Dosing Recommendations

*or one double strength tab

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Clinical Care: Immunizations

Immunize infants early before there is damage to the immune system

Routine immunizations per local guidelines Do not give BCG to any symptomatic infant

46

Clinical Care: Determining Infection Status

Priority to determine infected babies who need care and treatment rather than confirm the absence of disease

All HIV exposed infants should have virologic testing early, between 6-12 weeks of age

Interpretation should be done in the context of the clinical presentation of the infant

Antibody test is used in children >12 months of age If virologic tests are not available, WHO recommends

presumptive clinical diagnosis of severe HIV in infants <18 months of age

Breastfed infants with initial negative virologic tests should continue to be evaluated for clinical evidence of HIV infection

47

Follow-up Schedule for the HIV-exposed Infant Basic principles:

Early identification of infants who are sick or failing to thrive is critical

Careful and frequent clinical monitoring is requiredSystematic follow up is vital

• Appointment systems

• Medical records

• Family education and support

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4-6 weeks

Follow-up Schedule for theHIV-exposed Infant

Visit Schedule

2 months3 months

4 months5 months

6 months9 months

12 months 18 months15 months

12 months

HIV antibody testing

Follow-up schedule can be modified per local and national guidelines.

Virologic test

Monthly visits for the first 6 months, then every three months until HIV infection status determined

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Clinical Care: Assessment and Plan

What is the child’s HIV status? Does the child have any new problems? Does the child require any laboratory studies? Has the child received proper vaccinations?

Medications? OI Prophylaxis? When should the child return to clinic?

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Case Study: Yared

Yared is a 3 month-old male who is brought in for his monthly check up

Baby is breastfeeding at night, but is fed porridge during the day by Grandma, who does not know of mom’s status

Lately the baby has been feeding poorly. He has had diarrhea for the past two days

Mom notes that she thinks he isn’t growing as well Yared receives cotrimoxazole, but sometimes he misses

a dose when Grandma is caring for him, since she does not know that he takes this

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Case Study: Yared (2)

Yared’s physical exam is significant forBilateral cervical and axillary nodesNotable coughDiarrhea x2 during the examDepressed developmental stage

His growth has slowed The last time Yared was seen in the clinic, the

PCR machine was broken so he has not had any virologic testing done

53


Is there evidence of HIV infection?

Are there other problems or concerns?

What else should be done at this visit?

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Poor growth, adenopathy and diarrhea Findings consistent with HIV infection Cough probably URI He is at risk for development of PCP Situation complicated by feeding change Need to assess family situation

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Review cotrimoxazole medication and importance of adherence

Labs: FBC, DNA-PCR, CXR Stool sample Complete nutritional assessment Evaluation of cough including history of TB

exposure Psychosocial support, including adherence and

nutritional support for mother

56


The chest X-ray is normal Results of the FBC will not be ready until

tomorrow Mother sees the nutritionist and the counselor

before leaving the clinic

57


Yared returns in 2 weeks for his results HIV DNA PCR is positive Yared is diagnosed with HIV infection

Send a repeat DNA PCR for confirmation

Yared is referred for staging and initiation of ART at the local hospital

58

Family Health and Well Being

Families benefit from open and honest exchange of information about the child

Use simple language to explain the difference between exposure to HIV and HIV infection

Make sure to repeat the information at each visit All family members (infected and non-infected)

can benefit from psychosocial support

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Role of the Multi-Disciplinary Team

Ongoing communication between the members of the MDT is crucial for supporting the family and caring for the exposed infant

Each member of the team will have a different perspective and different pieces of information about the family and infant

Engaging parents in care and treatment can help to decrease the burden of disease, prevent orphaning, and keep families healthy

60

Summary

HIV exposed infants are at risk for HIV infection and rapidly progressive disease. It is important for providers to: Identify the infected children early Manage and prevent opportunistic infections Maintain and support healthy families

Exposed infants need to be monitored closely: History Physical exam Nutrition and growth Developmental assessment OI prophylaxis Determination & evaluation of infection status Assessment and plan for follow up

All members of the MDT are crucial in supporting the family and providing comprehensive care for the child

Infant Diagnosis

62

Learning Objectives

Outline key concepts in diagnosing HIV in infants

Review algorithms for diagnosing HIV Discuss virologic and antibody tests Understand clinical diagnosis Review roles of the parent and multidisciplinary

team

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Complexities of Infant Diagnosis

Difficult to diagnoseRoutine antibody tests cannot be usedSpecialized virologic tests are necessary

HIV infection is difficult to exclude Infants who breast feed continue to be at risk for

acquiring HIV infection

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HIV Antibody Testing

HIV antibody is not used for diagnosis during the first 12 months of life

Maternal HIV antibody (IgG) is transferred across the placenta during pregnancy

All infants born to HIV+ mothers will test HIV antibody positive

HIV antibody fades during first 9 - 18 months of life in uninfected infants

65

Specialized Virologic Tests

Specialized virologic tests must be used HIV DNA PCRHIV RNA PCRp24 AntigenViral Culture

Two positive virologic tests = HIV infection One positive virologic test = Presumed HIV

infection

66

Specialized Virologic Tests (2)

HIV DNA & RNA PCRSensitivity (true negatives) increases during first

weeks of lifeSensitivity can vary with assay and laboratory; assay

should be appropriate for viral subtypeTheoretically, sensitivity and specificity (true

positives) may vary in populations of infants receiving perinatal prevention regimens; no supportive data has been published

67

Specialized Virologic Testing

Breast-fed infants Remain at risk for acquiring HIV infectionMost are infected in utero, intrapartum and early

postpartum (by 6 weeks of age)A negative virologic test cannot reliably exclude HIV Must always be tested again 6-12 weeks after

cessation of breast feeding

68

Diagnosing HIV Infection in Children <18 months: When Virologic Tests are Available HIV-exposed infants should have virologic

testing early, between 6-8 weeks of ageDNA PCR & RNA PCR are most widely available

tests for infant diagnosis

Interpretation of virologic test results should ALWAYS be done in the context of the clinical presentation of the infant

Virologic testing is used primarily to identify the infected child, not to exclude infection in the exposed child

69

Early Virologic Testing

Positive ResultsIndicate HIV infectionA repeat virologic test should be done to confirmTreatment should not be withheld awaiting

confirmation if the infant is symptomatic and/or rapidly progressing

Negative Results

70

Early Virologic Testing (2)

Asymptomatic infantEarly negative virologic test generally implies that the child is not

infectedMost children remain at risk for acquiring HIV through

breastfeedingTesting with the HIV antibody test should be done at ≥12 months

or >6-12 weeks after the cessation of breastfeeding (whichever comes later)

Symptomatic infantRepeat virologic testingUse CD4 and clinical judgment. Consider starting treatment

depending on disease progression

71

Diagnosing HIV Infection in Children <18 months: Virologic Tests are not Available A presumptive diagnosis of HIV infection must

be made based on clinical findingsGood clinical reasoning can identify children at high

risk for HIV disease & rapid progression

The purpose of making a presumptive diagnosis is to initiate ART in the sick childInfants with severe manifestations of HIV infection

should not be denied treatment because their diagnosis cannot be confirmed

72

Presumptive Diagnosis of Severe HIV Disease in Children <18 months HIV antibody positive and

Diagnosis of Stage 4 or AIDS-indicator condition(s) ORSymptomatic with ≥ 2 of the following:

• Oral thrush• Severe pneumonia• Severe sepsis

Supporting factorsRecent maternal death Advanced HIV disease in the motherCD4% < 20% in infant

The diagnosis should be confirmed with HIV antibody when the child reaches 18 months

73

Clinical Judgment

Clinical judgment should guide:Interpretation of lab results

• Are results valid? Do the results make sense given the child’s health? Is the lab trustworthy? Could there be a specimen mix-up?

When to repeat PCR testing• Are the child’s symptoms consistent with HIV infection?

The decision to consider a child HIV-infectedThe decision to initiate ART

74

Discordance

Clinical findings may suggest the diagnosis of HIV infection even when virologic tests are negative

Use CD4 to assess immunologic status• Low CD4 is consistent with HIV diagnosis

Other diseases can have similar manifestations and should be ruled out if possible

Repeat virologic testing should be considered HIV antibody testing should be repeated at >18

months to confirm infection status

75

Diagnosing a Child Who Presents at 9-18 Months of Age Asymptomatic child Screen with HIV antibody

If positive, virologic testing is indicatedIf negative, no virologic testing is necessary

• If breast feeding, repeat antibody testing >6-12 weeks after cessation of breast feeding

Symptomatic child Screen with virologic testing

76

Diagnosing HIV in the Child >18 Months

HIV antibody should be used to diagnose HIV infection in children >18 months of age

Children >18 months with positive antibody test have HIV infection A positive antibody test should be confirmed by

duplicate testing A negative antibody test in children >18 months

excludes HIV infectionExcept in cases of continued breast feeding.

Antibody should be repeated 6-12 weeks post cessation of breast feeding

77

Multidisciplinary Team

Provide ongoing education, support, and counseling to parent

Identify problems and issues EARLY Form a bridge between parent and medical

provider Provide adherence support for both mother and

infant Introduce concept of infant diagnostic testing as

part of PMTCT program

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Multidisciplinary Team (2)

Support the decision to have early infant diagnostic testing

Review results of virologic testExplain implicationsExplore parental understandingExplore parental concerns

Review infant feeding decisions Emphasize need for ongoing care and treatment

as determined by results

79

Role of the Parent

Parent needs to understand: That infant diagnosis is an ongoing processThe importance of early testing, frequent monitoring,

and adherence to care Often the first to notice signs and symptoms Often has multiple complex roles and needs,

including self-care, caretaker role for other family members, feelings about transmission of HIV to the infant

Parent needs understanding and support

80

Case Study: Meseret

6 week old infant, Meseret, is brought to clinic for her first post-partum visit

Mom delivered in a village outside of the city where her mother and sister still live

She just returned home with Meseret and her 4 year old son

Mom was enrolled in a PMTCT program during pregnancy

What would you like to know about the baby and his family?

81

Meseret was born at home without problems Mother doesn’t know birth weight, but brought

Meseret to health station at 4 days of age, weighing 2.9 kg

Mom took her SD-NVP, but the baby didn’t receive any medication. Mom didn’t tell anyone at home about her status

Breast feeding primarily but left the baby with her sisters on two occasions. During that time Meseret was fed water and maybe some milk

Case Study: Meseret (2)

82


Dad is away working. Mom has not disclosed her HIV status to him

He comes home 1X/month and gives her money but she must work in the fields and sells produce to have enough money

She uses the general water tap in the neighborhoodNo running water in the house

What will you do next? What is usually done at a baby’s first visit?

83

Case Study: Meseret (4)—Pertinent Physical Exam Physical examination is remarkable for fairly

extensive oral thrush, and diffuse lymphadenopathy

The baby looks a little scrawny and seems irritable

What is your assessment of the child? What could be causing Meseret’s poor growth?

84

Case Study: Meseret (5)—Pertinent Physical Exam Growth Chart Infant Girl

Birth Weight- 2.9 kg

Weight at 6 wks- 3.4 kg

95%

90%

75%

50%

25%

10%

5%

85

Case Study: Clinical Questions

Physical examination is remarkable for fairly extensive oral thrush, and diffuse lymphadenopathy

The baby looks a little scrawny and seems irritable

86


Mom reports that the baby has not been feeding well for several days

You watch the child feed but she tires quickly and falls asleep. Mom says that this is what has been happening over the last several days

She also reports occasional watery stools She says that she had a ‘TB’ test at ANC and it was

negative Her mother (the child’s grandmother) seemed to be

coughing and had lost some weight, but she didn’t seem to be too sick

87


You send blood for HIV DNA PCR You work with mom around enhancing feeding and

arrange for the family to receive food packages You prescribe nystatin for the oral thrush The child also begins cotrimoxazole prophylaxis Mom is instructed to come back in one week to check

the baby again Mom does not make the appointment the following week.

What will the team do to address this missed visit?

88

Case Study: Meseret (8)—MDT

The case is discussed at the weekly multidisciplinary meeting and it is decided that the mom should be contacted immediately. Her cell number is no longer connected so the decision is made to make a home visit

A peer educator and a counselor travel to the listed address. Mom is not at home but they find the baby with a neighbor. Meseret seems sick and has loud breathing

What should they do?

89


Mom is due to return in a short time. She usually comes home late morning to feed the baby

When she arrives you escort her to the clinic with the baby

Meseret is brought in to the nurse who weighs her. Breathing seems fine now, but the child weighs the same as last visit

90

Meseret’s Growth Chart

Birth Weight- 2.5 kg

Weight at 1 mo.- 3.4 kg

Weight at 2 mos.- 3.4 kg

95%

90%

75%

50%

25%

10%

5%

91

Case Study: Meseret (10)—Pertinent Physical Exam On examination, the thrush is still visible and

lymph nodes are somewhat larger Infant diagnostic tests are not yet back. You ask

the nurse to call the lab and they have no record of the sample

What would you do now?

92


You decide that the child does not require hospitalization but ask mom to return in two days

You order:CXRCD4 count Repeat virologic testing

Test Results: The CD4 is 1200, 13%DNA PCR results are not readyCXR is normal

Does this child have HIV infection?

93


The team decides that the child most likely has HIV infection and requires treatmentThrush Failure to thrive ( WHO Stage III)Low CD4 (<25% for infant <11months of age)

What will you tell the mother? What will you do to confirm the child’s infection

status?

94


Meseret was continued on CTX, nystatin for thrush and started on ARVs

Both initial and repeat DNA PCR results were positive when test results were finally available

95

Case Study: Tsegenet

Mom brings her 10 week old baby, Tsegenet, for a return visit

The baby has been receiving cotrimoxazole since 4 weeks of age

She is breast feeding well and has not been sick An HIV test was sent at the previous visit and

mom is anxious to know the results The team discussed this family last week during

the multidisciplinary meeting

96

Case Study: Tsegenet (2)

DNA-PCR results were positive The team talked about how to share the news

with the parents What will you say to her mother when she

comes to the clinic?

97


Tsegenet appears well with a normal physical examination

Growth is plotted on the 25% percentile for weight, height and head circumferenceShe smiles, makes good eye contact, and reaches

out She is breast feeding and receiving additional foods and

water from an aunt Mom works several days each week

98

Case Study: Tsegenet (4)—Growth Curve

99

Case Study: Tsegenet (5)—Clinical Questions Given the laboratory result and the clinical

findings, do you think this child is HIV-infected? How will you manage the child? What will you tell the mother?

100


Mom returns with the baby in a month The repeat DNA PCR test is negative and the

baby is still thriving What will you do?

101

Case Study: Tsegenet (7)—Clinical Question Which of the following actions would you

consider?Repeat DNA-PCR testingCD4 Continue cotrimoxazoleMonitor closelyRapid antibody screen at 12 months

102

Case Study: Tsegenet (8)—Case Conclusion The team was unsure about the lab tests, but

decided to:Continue the CTX for nowSchedule more frequent follow-up, at the same time

as mom’s visitsWork with the mom and aunt to wean early

At 12 months Tsegenet tested HIV Ab negative

103

Key Points

Infant diagnosis can be a complex and lengthy process Early virologic testing should be used to identify the

infected infant at highest risk for disease progression Specialized virologic tests are used to diagnose HIV

infection in a child <18 months Two positive virologic tests confirm HIV infection in an exposed

infant

The presence of HIV antibody in a child >18 months defines HIV infection

104

Key Points

Clinical reasoning is critical to diagnosing infants with HIV Virologic tests may be unreliable or unavailable, making clinical

evaluation important HIV can be diagnosed without a definitive virologic test in an ill child

with clinical and immunological evidence of infection The diagnosis should be confirmed with virologic testing, response

to treatment and/or antibody testing >18 months The multidisciplinary team has numerous critical roles in this

process The parent or caretaker is the key player, and must be educated

and supported on this logistically, emotionally, socially and medically complicated path

Pediatric Disclosure:

Talking to Children about HIV

106

Learning Objectives

List important differences between adult disclosure and pediatric disclosure of HIV status

Discuss advantages/disadvantages of disclosing/not disclosing HIV status to a child

Discuss strategies to use during pediatric disclosure of HIV status

107

Disclosing to Children

Must consider:Needs, feelings, beliefs of the child and needs,

feelings, beliefs of the parent(s)/caretaker(s)• Pediatric health care providers traditionally advocate for

the needs of the child

• Multidisciplinary teams advocate for the needs of the family

Current and evolving developmental and cognitive stage of the child

Existing status of family dynamics and communication

108

Reasons Parents are Reluctant to Disclose

Fear of impact of disclosure on child’s psychological status and emotional healthReduce child’s will to liveDepression in child

Fear of inadvertent disclosure to others by childChild won’t keep secrets

Protecting child from social rejection and stigma Guilt about transmission

Association with sexual taboos

AAP, Pediatrics 1999;103:164Lipson M, Hasting Ctr Rpt 1993;23:6

109

Reasons Parents are Reluctant to Disclose (2) Difficulty coping with their own illness or illness

of other loved ones Established coping strategies within families

Traditional silence around illness and diseaseLimited communication within familiesDenial as coping strategy

Belief that child will not understand Children as hope for future

Avoid thinking of HIV keeps death away


110

Do You Believe Children Should Be Informed of Their HIV Status?

If yes, why?

If no, why not?

111

Reasons to Disclose

Undisclosed children mayDevelop fantasies about their illnessFeel isolated from sources of supportLearn HIV status inadvertently

Children often want and ask to know what is wrong; may already know diagnosis but are keeping the secret or waiting for the parent to tell

With other chronic and fatal illnesses children who know their status haveHigher self-esteemLower rates of depressionLower rates of parental depression

Recognition of child’s autonomyChildren achieve mastery over their lives as they age


112

How to Disclose

Disclosure is more than revealing HIV status Disclosure is an ongoing process Parents/caregivers should be encouraged to

begin and continue a dialogue about health issues with their child beginning at an early ageSimple explanation of nature of illness for youngest

children Disclosure about nature and consequences for older

children When to use the words “HIV/AIDS” will vary with

the needs of the child and family

113

How to Disclose (2)

Let the child be the guide Individualize the approach. Tailor discussion according

to child's:AgeCognitive development

• Use tools and language for different developmental capacities: drawing, storytelling, play, drama

Level of maturity• Assess coping skills of the child

Health status• Terminally ill child may benefit from discussion about death

rather than specific diagnosis

114

Assisting Families to Get Ready for Disclosure Preparation Education Planning Follow-Up

115

Assisting Families to Get Ready for Disclosure (2) Preparation

Why disclose now?What do you want to communicate to your child?What will be the most difficult questions for you to answer when

your child knows his/her HIV status?Acknowledge difficulty of disclosure and affirm motivation to

begin process

EducationTell parents how to explain HIV transmission to childAnticipate questions and responses from childDiscuss expectations for what will happen after disclosure

116

Assisting Families to Get Ready for Disclosure (3) Planning

When and where?Who will be there?What will you say?Plans after disclosure?

Follow-upFunctioning within the school and familyMonitor medical treatment adherenceDisclosure to peers and othersSupport groups, counseling

117

Why Counsel Children?

Helps children cope with emotions and challenges they experience when they discover they have HIV/AIDS

Helps children with HIV to make choices and decisions that will prolong their life and improve their quality of life

118

Why Counsel Children? (2)

Establish a helping relationship Help children tell their story Listen attentively Give correct and appropriate information Help them make informed decisions Help them recognize and build on their strengths Help them develop a positive attitude towards

life

119

Counseling Children

Model open discussion during visitsAddress questions to the childAsk child if he/she has questions

Discuss importance of dialogue and disclosure early and oftenRoutine part of pediatric HIV care

Use good counseling skills

120

Disclosure and Multidisciplinary Teams

Members of multidisciplinary teams may find themselves in conflict around disclosure to childrenSome team members may advocate for pediatric disclosureOthers, particularly those working with adult caregivers, may

resist disclosure

Multidisciplinary teams may hold/mirror conflicts occurring in familiesNeeds of the child vs. needs of the adultDifferent opinions of different adults

Important to retain family-focus and consider decisions in best interest of the child and the family

121

Case Study: Desta

Desta is an 11 year old girl. Her mother died five years ago and she has since lived with her aunt Amsale, uncle Yared and maternal grandmother Bogalech

Amsale was enrolled in the ART clinic during her pregnancy last year. Desta and Yared both tested HIV positive and were enrolled as well

Desta was eligible for ARV treatment based on a history of recurrent varicella zoster, chronic thrush and low CD4%

She began ZDV + 3TC + NVP but developed a Grade III rash. NVP was changed to Kaletra (LPV/r)

She has done well on treatment

122

Case Study: Desta (2)Resisting Medications Grandmother Bogalech brings Desta for her

monthly visit. She reports that everything is fine When asked about missed doses Bogalech

reports that Desta gets all of her medication. She reluctantly mentions that Desta is fighting with her about taking her medications

What Do You Want to Ask Bogalech?

123

Assessing Incomplete Adherence

Review current regimen Inquire about problems administering

medications – obtain a descriptive assessment Review WHO, WHAT, WHEN, HOW

124

Case Study: Desta (3)Refuses Medications Bogalech states that Desta no longer wants to

take her medications. She was a “good” girl in the past and took them without complaint though the orange pills always made her choke. Now she doesn’t want them any more

Desta keeps asking why she has to take these pills. She wants to know when she will finish taking them

125

Case Study: Desta (4)

When you ask Bogalech what Desta knows about her health she becomes quiet. You notice a few tears. She doesn’t want to discuss Desta’s problem. She says that the child is taking medications now and will be fine

What should you do?

126

Case Study: Desta (5)Refuses Medications Desta and Bogalech return home. You discuss the case

at next team meeting and decide to approach aunt Amsale when she comes for her monthly visit

When asked about Desta’s medication adherence Amsale notes that she has been resisting taking her medications

Amsale feels that Desta should know about her illness. She and grandmother Bogalech have fought about it several times. They both take care of Desta, but Amsale also has her babies to raise. She doesn’t want to fight with her own mother

Why do you think Grandmother Bogalech doesn’t want to discuss HIV with Desta?

What can the team do to help Desta and her family?

127

Case Study: Desta (6)Disclosure Process - Beginning a Dialogue Meet with family members alone, then together

Begin a discussion/dialogue about Desta’s health and behaviors

Address Bogalech’s concerns about DestaWork with family members to enhance

communication

Offer counseling for Desta, other family members

Follow general counseling guidelines Continue to monitor adherence closely

128

Case Study: Desta (7) Beginning a Dialogue After several family meetings, Amsale takes the

lead and starts to talk with Desta about her health. Bogalech doesn’t take part in the conversations, but doesn’t prevent them

Amsale, who is also taking ART, begins to take her medicines with Desta. She talks about staying healthy and having strong blood. After several weeks Desta begins to ask questions and stops fighting about her medications. Amsale and Desta become pill buddies and complain to each other about the nasty blue pills

129

Case Study: Desta (8)Desta Continues to Ask More Questions Several months later Amsale brings Desta to her

medical appointment. She tells the clinician that she thinks it is time to tell Desta more about her illness. Bogalech doesn’t want to take part but has agreed to let Amsale talk with Desta

Amsale asks for help

What would you do to assist Amsale and her family?

130

Case Study: Desta (9) Disclosure of HIV Status to Desta The team works with Amsale and Yared in

preparation for meeting with Desta. Amsale asks that the nurse and physician help during the session

How do you feel about talking with Desta?What will you say?

131

Case Study: Desta (10)Follow-up Care Amsale, Yared, the pediatrician, and the nurse

meet with Desta to disclose her HIV status. The meeting is very emotional for all participants. Desta and Amsale choose to meet with the counselor on a weekly basis to continue talking about their concerns

132

Case Study: Henok

Henok is 6 years old and he has a 3-year-old sister, Melke. The children’s parents have died, and both children now live with their maternal aunt Rahel and her family. Rahel is pregnant and she is being followed at the clinic

During a recent visit Rahel reports that both Melke and Henok have been sick a lot. She requests that both Melke and Henok be tested for HIV/AIDS. She also reports that the children do not eat or sleep well

What additional information do you want? How will you go about arranging for testing of the children? How will you explain the testing to the children?

133

Case Study: Henok(2)

During his blood draw for HIV testing, Henok asks the nurse what happened to his mother and if something bad is going to happen to his sister and he. He seems very worried and frightened

How will you respond to his questions? How will you help his aunt in her parenting of Henok and

Melke? What should happen, if anything, while the family is

awaiting test results?

134

Key Points

Disclosure of HIV status to a child is guided by the needs of the child and their caregivers

Disclosure should be part of an ongoing dialogue about health and treatment

Disclosure should be guided by the age, developmental and emotional stages, and health status of the child

Disclosure is difficult!

135

Key Points

Disclosure for children Involve the child as well as one or more adultsConsider:

• Child’s age, developmental stage, feelings, health status

• Caregiver’s beliefs and feelings • Family dynamics

Disclosure for children should not be viewed as a one-time event but as an ongoing processes requiring a systematic approach and the varied skills of a multidisciplinary team

Care of HIV-Infected Infants and Children

137

Learning Objectives

Describe goals of care for HIV-infected infants and children

Describe common clinical manifestations of HIV disease in children

Describe appropriate use of the major components of routine care for HIV-infected infants & childrenCategorize disease stagePrescribe Cotrimoxazole Preventative TherapyPerform tuberculosis screeningEvaluate ARV eligibilitySchedule pediatric visits

138

Goals for Care of HIV-Infected Infants & Children Model of care

Family-centeredHIV primary careMultidisciplinary team

Maximize health & prevent disease progressionPrevent early deathPrevent OIMaximize growth and developmentReduce hospitalization rateReduce frequency of intercurrent illnesses

139

HIV in Children

HIV during infancy = primary infectionAcquisition of HIV can occur in utero, intrapartum, postnatally

(through breast feeding)Very high viral load: peak at 6-12 weeks of life

Multiple factors influence rate of disease progression:Maternal advanced diseaseMaternal vital statusTiming of transmission (peripartum vs. late)Genetic susceptibilityVirus characteristics

Likelihood of disease progression is associated with child’s CD4 count and HIV-1 RNA copy number

Clinical Manifestations of HIV/AIDS

141

Clinical Infections

Recurrent bacterial infectionsAccount for about 20% of AIDS defining illnesses in infants and

childrenMost are caused by encapsulated organisms such as S.

pnuemoniae and Salmonella, others are Staphylococcus, enterococcus etc

Most common serious infections are – pneumonia, bacteremia, sepsis and meningitis (account for more than 50% of infections in HIV infected children)

Management Same as in non HIV- infected children Occasionally may require longer duration of treatment

142

Common Opportunistic Infections

Opportunistic infections (OI): Generally occur with severe immune

suppression Young children have primary infection rather

than reactivation Lack of immunity leads to more severe course

than in adults

143

Common OIs: Pneumocystis Pneumonia (PCP) Parasitic infection

Pneumocystis jiroveci (formerly Pneumocystis carinii)

Diffuse and severe pneumonia Characterized by gradual

onset of hypoxia, fever, cough and respiratory distress

Peak incidence is between the age of 3 – 6 months

Hypoxia with normal CXR/or there may be diffuse alveolar disease with granular pattern

Management Intravenous/oral trimethoprim

(15 – 20 mg) sulfamethoxazole (75 – 100 mg)/24hrs every 6 hrs for a total of 21 days Adjunctive corticosteroids 2

mg/kg/24 hrs for 7 – 10 days then gradual tapering over 7 – 14 days

Alternative if intolerant to TMP/SMX: Pentamidine

Prophylaxis Lifelong after infection HIV-infected children

dependent on clinical stage and/or immunologic suppression

144

Common OIs: Mycobacterium Avium Complex (MAC)

May cause disseminated disease in children

Symptoms are non specific: weight loss or failure to thrive, fever, abdominal pain, diarrhea, and lymphadenopathy

Diagnosis can be made only by Isolation of MAC from blood, bone marrow or tissue

Treatment in childrenClarithromycin- 7.5 mg

/kg/dose twice daily plus Ethambutol- 15mg /kg /day

Prophylaxis (CD4% < 15)Clarithromycin 7.5 mg/kg

twice daily

145

Common OIs: Candida Infections

Oral candidiasis and diaper dermatitis are the most common in HIV infected children

Three forms Atrophic candidiasis Chronic hyperplastic

candidiasis Angular Cheilitis

Dysphagia and poor oral intake, irritability indicates involvement of the esophagus

Others: invasive disease, candidal dermatitis, onychomycosis

Management Oropharyngeal:

Fluconazole 3-6mg/kg daily for 7-14 days

Esophageal disease: Fluconazole 6mg/kg on day one then 3-6mg/kg daily for minimum of 14-21 days

146

Common Viral Infections: Herpes simplex virus The most common cause

of stomatitis in children 1 - 3 years of agePain in the mouth,

salivation, fetor oris, refusal to eat, high fever, vesicular lesion that rupture leaving shallow ulcers

Typically symptoms subside with in a week but in HIV infected children it is prolonged, and extensive Dissemination to involve the skin and other organs

Treatment: Acyclovir

147

Common Viral Infections

ChickenpoxMay be prolonged and

complicated by bacterial infection or visceral dissemination or pneumonitis

Herpes ZosterRecurrent, atypical and

chronic, and may need use of acyclovir

Measles May occur despite

immunization and may present without the typical rash

CMVRetinitis, pneumonitis,

esophagitis, gastritis with pyloric obstruction, hepatitis, encephalitis are reported

148

Common CNS Manifestations

Occurs in 50 – 90% of perinatally infected children in developing countries

Most common form is progressive encephalopathyLoss or plateau of developmental milestonesCognitive deterioration Impaired brain growth resulting in acquired microcephalyApathy, spasticity, hyperreflexia and gait disturbances and loss

of language and other motor skillsCT shows cerebra atrophy in 85% of children

Focal neurologic signs and seizure may occur with CNS lymphoma, toxoplasmosis, tuberculoma, stroke

149

Common Cardiovascular Manifestations Dilated cardiomyopathy and left ventricular

hypertrophy are common With advanced disease high frequency of

autonomic instability leads to rhythm abnormality Gallop rhythm, tachypnea, Hepatosplenomegaly

indicates CHF Anticongestive therapy is effective

150

Common GI Manifestations

Most frequent GI symptoms: persistent or recurrent diarrhea with malabsorption, abdominal pain, dysphagia and failure to thrive

A variety of pathogens cause GI symptoms: Bacteria (salmonella, campylobacter, MAC) Protozoa (Giardia, cryptosporidium, Isosporia, microsporida) Viruses (CMV, HSV, Rotavirus) Fungi (Candida)

MAC and protozoal infections are severe and protracted

Other GI manifestations are Chronic liver inflammation with or without jaundice Pancreatitis with or without abdominal pain Chronic cholecystitis

151

Common Skin Manifestations: Bacterial skin infections Folliculitis, cellulitis, skin

abscesses impetigo, furunculosis and paronychia may occur with increasing frequency

Staphylococcus aureus is the cause in most bacterial skin infections

Good hand washing is needed to prevent spread of lesion

Treatment: AntibioticsSource: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs

Impetigo

152

Common Skin Manifestations: Seborrheic Dermatitis/eczema Extensive and an early

non specific sign of HIV infection in infants

Thick yellow scales on the scalp but thin scales over the rest of the body

High recurrence Treatment

Topical steroids

Seborrheic dermatitis of the axilla

Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs

153

Common Skin Manifestations: Pruritic Papular eruptions (PPE) Chronic papular lesion Etiology unknown Evenly distributed over the trunk and extremities A marker of worsening immunosuppression and

may be stigmatizing Risk of secondary bacterial infection Treatment:

Antihistamines and steroids

Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs

154

Common Skin Manifestations: Scabies

Pruritic papular eruptions In infants and children tend to involve the sole

and the palms Norwegian Scabies: generalized scaling and

enlarged crusted plaques Treatment:

Benzylbenzoate lotion 25%

155

Common Hematologic Manifestations

Unexplained Anemia: 20– 70% of HIV-infected children

(Hb < 8g/dL)Causes: chronic infection,

poor nutrition, autoimmune factors, virus associated conditions (Parvovirus B19) and drugs

Leukopenia: in up to 1/3 of infected children (ANC < 1000/mm3)

Thrombocytopenia: in 10– 20% of patients

(< 50,00/mm3)

156

Common Malignant Diseases

Generally less frequent compared to adults and represent less than 2% of AIDS defining illnesses in children

Most frequent: Non Hodgkins lymphoma Primary CNS lymphoma Leiomyosarcoma

Epstein-Barr virus is associated with most cases of lymphomas and all cases of leiomyosarcoma

Kaposi sarcoma due to human herpes virus 8 occurs less frequently than in the adults

Routine Care for the HIV-Infected Child

158

1. History (past, interim, parental concerns)

2. Nutrition evaluation3. Developmental assessment 4. Physical examination5. Laboratory evaluation6. Staging/classification7. Opportunistic infections8. ARV eligibility9. Assessment & plan

Components of Routine Care for the HIV-Infected Child

159

1. History

Why is history important?Develop clinical profile for older children entering the

programIdentify changes in health status since last visit Identify changes in home setting that may affect

child’s health PAST HISTORY

Newly enrolled older children • HIV-related illnesses• Hospitalizations• Medications (ARV, OI prophylaxis)

160

1. History (2)

Interim History New health problems

Signs & symptoms checklistHIV-related illness

Current MedicationsantiTB medicationsMedications for OI prophylaxis e.g. CotrimoxazoleOther alternative medications (herbal preparations)

161

2. Nutritional Evaluation

At every visit:Nutrition and feeding history – exclusive

breastfeeding or mixed feeding?Weigh, measure and examine childUse growth curves to monitor growth pattern

Any child who is not thriving needs extensive nutritional history

162

Failure-to-Thrive

The failure to sustain a normal velocity of weight and/or height growth during the first 3 years of life – downward crossing of 2 percentiles over time

Can be quantified using growth curves May be indication:

Of HIV disease in exposed infantFor ARV treatment in infected infant/childOf ARV treatment failure in child on therapy

163

3. Developmental Assessment

At every visit Ask about the infant’s developmentSimple questions should focus on four critical

developmental domains; cognitive, motor, language, and social

This can be done through observation during the physical exam or asking the parent

The developmental checklist may be helpful Delayed acquisition of developmental milestones

or loss of previously acquired skills can be the first sign of HIV encephalopathy

164

3.Developmental Assessment (cont’d)

Developmental Checklist 1 month: raises head, crawling

movement, alerts to sound 2 months: head midline, lifts

chest off table, smiles socially 4 months: rolls front to back,

laughs 6 months: sits unsupported,

babbles 9 months: pulls to stand, says

“mama” 12 months: walks alone, two

words

165

4. Physical Examination

At every visit Perform careful physical examination

Initial exam should be comprehensive including examination of all organ systems

Identify any HIV related physical findings; thrush, lymphadenopathy, organomegaly, dermatitis,encepatholpathy etc

Subsequent exams can be guided by findings on the symptom/sign checklist

166

5. Laboratory Evaluation

Which Laboratory Tests Need To Be Done? Complete Blood CountCXR if clinically indicated CD4 CountPregnancy test for sexually active adolescent femalesCD4 number and percent

• When infant is determined to be HIV-infected

• Upon enrollment for older children

• Every six months there after

167

The Use of CD4 Count in Children

CD4 counts and percentages in healthy infants at birth are very high at birth and during the first year of life and then decline

The absolute CD4 count during the first year of life is more than 3 times that of adults

Because of these differences, adult values do not apply until age 6CD4 count of 500 is considered okay for a 7 year old but is

severe suppression for a 6 month old

CD4% is a more stable value than absolute number, so percentage is preferred in children under 5 years of age

168

Calculating the CD4 Percentage

Calculate the CD4 percentage for a 13 month old HIV-infected infantCD4 absolute is 640mm3WBC is 10,000mm3N-38%, L 48%, M-12%, E-2%Calculate the TLC = 10,000 x .48 = 4800The CD4 percentage= 640 X 100 = 13% 4800

169

WHO Immunologic Categories

Classification of HIV-associated

immunodeficiency

Age related CD4 values

<11mo

(%)

12-35mo

(%)

36-59mo

(%)

5 years

(mm3)

Not significant >35 >30 >25 >500

Mild 30-35 25-30 20-25 350-499

Advanced 25-30 20-25 15-20 200-349

Severe <25 <20 <15 <200 or <15%

170

6. Staging and Classification

Clinical staging should be performed at every visit

Why is clinical staging important?To assess disease severityTo monitor disease progressionCriteria for ARV therapy

171

Clinical Staging of Pediatric HIV/AIDS

Old WHO clinical stages:Three stagesDidn’t capture many disease manifestationsDidn’t include measures of immunologic status

New WHO clinical staging: Four clinical disease categories; asymptomatic, mild,

advance and severe Expanded comprehensive list of associated conditions

based on prognosisStandardized criteria for presumptive and definitive

diagnosis

172

WHO Classification of HIV Associated Clinical Disease

Clinical Classification WHO Clinical stage

Asymptomatic 1Mild 2

Advanced 3Severe 4

173

WHO Staging for <15 Years Old

Clinical Stage 1 (Asymptomatic)Asymptomatic

PGL

Clinical Stage 2 (Mild)Hepatosplenomeagly

Papular pruritic eruptions, Extensive wart virus infection

Extensive molluscum contagiousum Fungal nail infections,

Recurrent oral ulcerationsLinear gingival erythema (LGE)

Angular cheilitis Parotid enlargement

Herpes zoster Recurrent or Chronic URTI (otitis media, otorrhea, sinusitis)

174

WHO staging for <15 Years Old (2)

Clinical Stage 3 (Advanced)Conditions where a presumptive diagnosis can be made on the basis of clinical signs or

simple investigations: Moderate unexplained malnutrition not adequately responding to standard therapy

Unexplained persistent diarrhea (14 days or more) Unexplained persistent fever (intermittent or constant for longer than one month)

Oral Candidiasis (outside neonatal period), Oral hairy leucoplakia

Acute necrotizing ulcerative gingivitis/periodontitisPulmonary TB

Severe recurrent bacterial pneumoniaConditions where confirmatory diagnostic testing is necessary:

Unexplained anemia (<8mg/dl),and/or neutropenia (<500/mm3) and/or thrombocytopenia, (<50,000/mm3) for >1 month

Chronic HIV associated lung disease including bronchiectasisSymptomatic lymphoid interstitial pneumonitis (LIP)

175

WHO staging for <15 Years Old (3)Clinical Stage 4 (Severe)

Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations:

Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia

Recurrent severe bacterial infections (empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)

Chronic herpes simplex infection (orolabial or cutanoeus > 1 month, visceral of any duration)Kaposi’s sarcoma, esophageal candidiasis, CNS toxoplasmosis, HIV encephalopathy

Conditions where confirmatory diagnostic test is necessary:CMV infection (retinitis or infection of organs other than liver, spleen or lymph nodes; onset at the age

of 1 month or more)Extrapulmonary cryptococcosis including meningitis

Any disseminated mycosis (e.g. extrapulmonary histoplasmmosis, coccidiomycosis, penicillosis)Cryptosporidiosis, isosporiasis

Disseminated non-tuberculous mycobacteria infectionCandida of the trachea, bronchi or lungs

Acquired HIV associated rectal fistula, cerebral or B-cell lymphomaProgressive multifocal leucoencephalopathy (PML)

HIV associated cardiomyopathy or HIV associated nephropathy

176

WHO Classification of HIV-associated Immunodeficiency in Infants and Children

Immunological Classification

<12 months (CD4 %)

12-35 months (CD4

%)

36-59 months (CD4

%)

> 5 years(CD4

cells/mm3)

Not significant > 35% > 30% > 25% > 500

Mild 30-35% 25-30% 20-25% 350-499

Advanced 25-30% 20-25% 15-20% 200-349

Severe < 25% < 20% < 15% < 200 or 15%

177

Case 1: Henok

Henok is 12 months old with HIV infection. He has had no major illnesses or hospitalizations

He has bilateral cervical, inguinal and axillary adenopathy, persistent oral and genital candidiasis, and is being treated for his 4th episode of otitis media. His growth is at the 10th percentile

What WHO stage is Henok?

178

7. Opportunistic Infections

Occurs with severe immune suppression Young children have primary infection rather

than reactivation as in adults Immature immune system of the infant leads to

more fulminant course than in adults Prophylaxis prevents disease progression and

morbidity and mortality!

179

PCP Pneumonia

Parasitic infection Pneumocystis jiroveci (formerly Pneumocystis carinii)

One of the most commonly occurring opportunistic infections in infants and young children with a very high mortality rate

Without prophylaxis, 40% of infants and children with AIDS experience PCPProphylactic cotrimoxazole is one of the most

important interventions for HIV-exposed infants and HIV-infected infants and children

180

PCP Pneumonia

Clinical presentation characterized by sudden onset of hypoxia, fever, cough and respiratory distress

In some, sub-acute presentation Peak incidence occurs between the age of 3–6

months with highest mortality in children <1 year of age

Patients may have hypoxia with normal CXR or there may be diffuse alveolar disease with granular pattern

181

Prophylaxis Regimens

Cotrimoxazole suspensionRecommended dosing is based on 4mg/kg of the

trimethoprim portion once each day Use weight band chart for dosing

Toxicities* include RashFeverBone marrow suppression (neutropenia)

*infrequent in infants

182

Tuberculosis: Background

Most common opportunistic infection among HIV-infected patients in Africa, SE Asia

Leading cause of AIDS-related deaths worldwide: 1/3 of all AIDS-related deaths are due to TB

Can be prevented by:Treatment of latent TB infection (preventive therapy)Use of antiretroviral therapy

183

Special Issues for Children

High rates of co-infection (HIV and TB)Zambia: 69% hospitalized with clinical TB test HIV+Cote d’Ivoire: 23.4% Johannesburg: 42%

Higher risk of progression from latent to TB disease compared with adults

Associated with severe complicationsMeningitisMiliary TB

184

Special Issues for Children (2)

Difficult to diagnoseLimited yield of diagnostic procedures:

• Poor sputum production

• Low yield of gastric aspiration

• Sputum induction and bronchoscopy not routinely usedMultiple varied clinical manifestationsOverlap with other HIV disease manifestationsBCG vaccination results in false positive Tuberculin

Skin Testing (TST)Limited sensitivity of TST in HIV-infected children

185

TST Survey in Children, Botswana

0

10

20

30

40

50

60

70

80

0 mm 1-9mm 10-14mm >15mm

% TST positive

MMWR 1997, 46(36);846TST Reaction Size (mm)

186

Impact of BCG Vaccination

WHO estimates 79% of population vaccinatedGiven at birth or during newborn period

Thought to prevent severe TB complications in young children, i.e. disseminated disease and meningitis

Can result in reactive TSTNo reliable method to distinguish “true-positive” TST

caused by M. tuberculosis infection from “false-positive” TST caused by BCG vaccination

187

Tuberculosis Screening

Targeted history at each evaluation Symptom checklist Inquire about household contacts with TB

• Establish risk to infant/child• Make sure those with TB in the household are appropriately

treated

Tuberculin skin testing (TST) ofChildren with positive symptom screen or clinical findings

consistent with TBHousehold contacts of adult with TB disease Annually for all children with HIV infection beginning at 1 year of

age

188

TST Placement and Reading

Intradermal placement of .1 ml 5TU PPD Read 2-3 days after placing test by trained

worker or health care provider Feel for induration

Color change without induration is not included in measurement

Use a ruler or calipers Document exact size (mm) of reaction ≥ 5 mm induration considered positive in an HIV-

infected child

189

Positive TST (>5mm)

Exclude active TB as per local and national guidelines

Symptom checklist and physical examChest X-ray when available

For TB diseaseFollow local and national guidelines

For LBTI INH (10-15mg/kg, maximum 300 mg) daily for 6 monthsVitamin B6 generally not given to children unless:

• Severe malnutrition• Breast feeding • AIDS• Pregnant adolescent

190

8. ARV Eligibility

WHO Recommendations for Initiating ART in Infants and Children

Children with WHO Stage 4 and most WHO stage 3 should initiate ARTCD4 can be used to guide ART initiation for some Stage 3

diagnoses (TB, LIP)

Children with WHO Stages 1 and 2 should only initiate ART if they have evidence of advanced immune suppression

Children with severe immune suppression independent of WHO stage

191

9. Assessment & Plan

Synthesize components of evaluationDiagnose and manage complicationsOrder laboratory studiesRefer for counseling/support groupsFollow-up appointment

192

What is the Follow-up Schedule for the HIV-Infected Child?

Ages 0-6 months

6-24 months

>24 months

Symptomatic

Asymptomatic

Receiving ARV

Monthly

Every 3 months

Every 3 months

Every 6 months

Weekly for 8 weeks, monthly thereafter

Pediatric Antiretroviral Therapy

194

Learning Objectives

Describe WHO clinical and immunological criteria for ART initiation in infants and children

Describe preparation of the family for ART Identify and manage ARV toxicities Recognize treatment failure

195

Children Are Not Small Adults

Age-related differences between children & adultsBody compositionRenal excretionLiver metabolismGastrointestinal function

Drug metabolism in children varies with age and maturation leads to differences in:Drug distribution and clearanceDrug dosing and drug toxicities

• Pharmacokinetic (PK) data not consistently available in young children

• Variations in PK (between and within individuals) frequently greater in children

196

Requirements Prior to ART

Confirm HIV Diagnosis and EligibilityLaboratory confirmation as soon as possibleWHO Clinical and Immunological Staging Criteria

Identify and fully counsel caregivers Confirm availability of support services (family, social,

inpatient care etc.) Ensure access to nutrition and prophylaxis Availability of consistent caregiver for

administration/supervision – will vary with family structure

Ability to keep follow-up appointments

197

WHO Criteria for ART Initiation in Infants and Children < 13 years Children with WHO Stage IV and most WHO

stage III should initiate ARTCD4 can be used to guide ART initiation for some

stage III diagnoses (TB, LIP)

Children with WHO Stages I and II should only initiate ART if they have evidence of advanced immune suppression

Children with severe immune suppression independent of WHO stage

198

New WHO Criteria for Starting ART in Infants & ChildrenWHO Pediatric Stage

Availability of CD4 cell assay

Age specific recommendation

<18 months >18 months

IVCD4

Treat AllNo CD4

IIICD4

Treat AllTreat all except those with TB, LIP,OHL, thrombocytopenia, also take into account CD4 value

No CD4 Treat all

IICD4 CD4 guided

No CD4 TLC -guided

ICD4 CD4 guided

No CD4 Do not treat

199

WHO Age-Related CD4 Values for Starting ART in Infants & Children

Immunological markera

Age specific recommendations to initiate ARTb

<12mo 12-35mo 36-59mo >5 years

CD4% 25 % 20% 15% 15%

CD4 count 1500cells/mm3 750 cells/mm3 350cells/mm3 200cells/mm3

To be used only in absence of CD4 assay:

Total Lymphocyte count

4000cells/mm3 3000cells/mm3 2500cells/mm3 1500cells/mm3

200

WHO Criteria for Starting ART: Infant with Presumptive Diagnosis-Severe HIV Disease HIV antibody positive and

Diagnosis of Stage IV ORSymptomatic with ≥ 2 of the following:

• Oral thrush• Severe pneumonia• Severe sepsis

Supporting factorsRecent maternal death Advanced HIV disease in the motherCD4 <20%

Laboratory confirmation should be sought as soon as possible depending on available resources

201

Eligibility of Children >13 years of age

WHO stage 4 irrespective of CD4 cell countWHO stage 3 HIV disease and CD4 < 350CD4 < 200 irrespective of WHO stage

In situations of rapidly deteriorating health status and lack of virologic test availability, a presumptive diagnosis can be done

A presumptive clinical diagnosis of severe HIV necessitates management of presenting acute illnesses and management of HIV including the initiation of ART

202

Preparing for ART

Complex adherence challenges for childrenRequires collaboration of child, parent, and all

secondary caretakersFamily needs support around long-term therapy,

changing regimens, and dosesIssues of disclosure and multiple caretakers

complicate complete adherenceOngoing support for evolving adherence needs as

child develops with age

Prepare family for adherence

203

Points of Caution

Consider any medical contraindications to first-line regimens using Medical historySymptom checklistPhysical examinationLaboratory studies (renal function, liver function, and

CBC, pregnancy test in sexually active females, and CXR if clinically indicated)

204

Medical Contraindications to ART

Severe Anemia (Hb<6.9 gdl) Contraindication to AZT, replace with d4T

Severe Neutropenia (ANC<250 mm3) AZT use requires close monitoring. Can substitute d4T if ANC falls

Severe Renal Insufficiency (Creatinine > 3 times normal) Contraindication to ARV use. Patient not eligible for ART

Severe Hepatic Insufficiency (LFTs > 5 times normal) Contraindication to NVP use. Use EFV in children older than 3, PI treatment suggested for small children

History of prior ARV use Potential for ARV resistance. Consult for expert management

Current use of rifampin containing TB regimen- Interactions with NVP. If CD4 is high, consider deferring ART or use ritonavir containing regimen for children under 3 and EFV containing regimen for children older than 3

205

First Line Regimens

Preferred pediatric first line regimes: Children under the age of 3

AZT+3TC+NVP or d4T+3TC+NVP orABC+3TC+NVP

Children older than 3 years (>10kg)AZT+3TC+NVP/EFV or d4T+3TC+NVP/EFV orABC+3TC+NVP/EFV

Additional dual NRTI backbone include ABC+ AZT or ABC+d4T

206

Special Circumstances

WHO recommends Triple NRTI(AZT+3TC+ABC or d4T + 3TC +ABC)

as alternative option for initial therapy under certain circumstances:Infants and children < 3years receiving TB treatment

where NVP or PI cannot be used because of interactions with rifampin

Pregnant adolescent with CD4 cell > 250/mm3 in which both NVP and EFV are contraindicated and PI based regimes are not available

207

Dosing for Pediatric ARVs

Dosing is weight dependent and must be adjusted for significant weight gain/loss

Check weight and height at each visit and adjust dosage when necessaryFailure to adjust for weight gain can lead to

underdosage and development of resistanceFailure to adjust for weight loss can lead to

overdosing and toxicity

Review dose changes and reasons for changes with family

208

ICAP Pediatric ARV Dosing Chart

209

Zidovudine (AZT)

Formulation Syrup:10 mg/ml Capsules: 100 mg; 250mgTablet: 300mg

May be crushed and combined with food Light sensitive, needs to be stored in a glass jar Should not be used with d4T because of

possible antagonism Monitor side effects and toxicity

210

Lamivudine (3TC)

FormulationOral solution: 10 mg/ml Tablet: 150 mg

Generally well tolerated Store solution at room temperature Tablet can be mixed with water or food and

taken immediately Use within one month of opening the bottle Monitor side effects and toxicity

211

Stavudine (d4T)

FormulationOral solution: 1mg/ml Capsules: 15mg, 20mg, 30 mg

Solution must be refrigerated Capsules may be opened and mixed with small

amount of food Should not be used with AZT because of

possible antagonism Monitor side effects and toxicity

212

Abacavir (ABC)

Formulation Oral solution: 20mg/mlTablet: 300mg

Can be given with food Tablet can be crushed and mixed with small

amount of water or food and immediately ingested

Monitor side effects and toxicity

213

Nevirapine (NVP)

FormulationOral solution: 10 mg/ml Tablet: 200 mg

Can be given with food Store suspension at room temperature; must be shaken

well NVP is initiated at a lower dose and increased in a

stepwise fashion Monitor for side effects and toxicity

Liver toxicity can occur but is less common than in adults, can be fatal

Discontinue for grade 3 toxicity: substitution with efavirenz has been successful in adults, but little data is available for children

214

Efavirenz (EFV)

Formulation Syrup: 30mg/ml (for children > 3 years) Capsules: 50mg, 100mg, 200 mg

Not indicated for children under 3 years of age or less than 10 kg Capsules can be mixed with sweet foods or jam to disguise peppery

taste Can be given with food but avoid high-fat meals which decrease

absorption by 50% Best given at bedtime to reduce CNS side effects

Monitor for side effects and toxicity Should not be prescribed for adolescent females who are at risk for

becoming pregnant because of teratogenicity Rash is more frequent in children than adults but it is generally milder

215

Special Considerations in Prescribing First Line Regimens Never prescribe efavirenz to a child under the

age of 3. Proper dosing has not been determined for any child <3yrs or <10kg

Stavudine (d4T) liquid requires refrigeration. Families can be taught to open capsules but this may be complex. Zidovudine may be preferable

In children who were previously exposed to NVP as a PMTCT regimen, NNRTI resistance may develop. While this resistance generally fades within the first year, this may impact the efficacy of the NNRTI-based regimen

216

How to Monitor ARV Therapy

Clinical Laboratory Treatment adherence Program adherence: keeping visit appointments

217

Clinical Monitoring

Weekly visits for the first 8 weeksAssess adherence, side effects/toxicity, immune

reconstitution and growthSymptom checklist and targeted physical exam Review and recalculate dose, if needed, at each visit

based on weight Dispense one week of medication To decrease burden on the family, follow-up visits can

be combined with other health care visits

218

Clinical Monitoring (2)

Monthly visits after the first 8 weeks if adherence is excellent

At each visit: Interim historySymptom checklistTargeted physical examGrowth and nutritional assessmentDevelopmental assessmentPsychosocial assessmentAdherence with caregiver and older child when appropriateARV prescription (recalculate doses)Referral for support services as needed

219

Laboratory Monitoring

CD4 count and percent Every 6 months to monitor ART efficacy

Hg at 1 month for those on AZTThereafter, if symptoms indicate

Abnormal findings on history or physical may warrant additional laboratory testing

Abnormal lab results may indicate ART toxicities, intercurrent illnesses, and/or advancing disease

220

Defining ART Success

Mild or no reported side effects Excellent adherence Improved clinical status in 6 months

Improved growthImprovement in neurological symptoms and

developmentNo new AIDS defining illnessFewer intercurrent illnesses

Improved or stabilized immune status in 6 months

221

Attending to ART Toxicities

In general, ART is well tolerated Similar to adult ART care, high level of attention

needs to be given to potential adverse effects such as: ART toxicity, immune reconstitution, intercurrent illness, disease progression, drug interaction

Please refer to detailed toxicity information covered in the adult sections

222

Attending to ART Toxicities

Remember: Clinical judgment is important:

Something other than ART may be causing the adverse effect

Lab error might confound the assessment of toxicity severity

Every individual is unique and might not fit precisely into a table or guideline

Response to management plan may be the only way to determine if symptoms/problems are due to ART toxicity

223

Switching Single Drug for Toxicity

First- line drug

Major potential toxicity Drug substitution

ABC Hypersensitivity reaction—DO NOT RECHALLENGE

AZT

AZT

Lactic acidosis ABC

Severe gastro-intestinal intolerance d4T or ABC

Severe anemia or neutropenia d4T or ABC

d4T

Lactic acidosis ABC

Lipoatrophy / metabolic syndrome

AZT or ABCPeripheral neuropathy

Pancreatitis

224

Switching Single Drug for Toxicity

First- line drug Major potential toxicity Drug substitution

EFV

Persistent severe CNS toxicity NVP

Potential teratogenicity NVP

NVP

Severe hepatotoxicity EFV

Hypersensitivity DO NOT RECHALLENGE: useTriple NNRTI (disadvantage, may be less potent)

PI (disadvantage, premature start of

2nd line ARV drug)

Severe life threatening rash

(Stevens Johnson Syndrome)

225

Recognizing Treatment Failure

Inadequate adherence is the most common cause of treatment failure in children

Issues to consider with regard to adherence:Who administers drug?How is drug administered? Is it the drug?

Resistance to specific agents may have a significant impact on treatment efficacyResistance to specific drugs can develop secondary to

inadequate adherence, inadequate drug levels and selection of pre-existing mutations with selective pressure of present regimen

226

Clinical Indications of Treatment Failure

Lack of or decline in growth rate in children who show an initial response to treatment (WHO Stage III or IV)

Loss of neurodevelopmental milestones or development of encephalopathy (WHO Stage IV)

Occurrence of new opportunistic infections or malignancies or recurrence of infections, such as oral candidiasis that is refractory to treatment or esophageal candidiasis (WHO Stage III or IV)

227

Immunologic Indicators of Treatment Failure

Development of age-related severe immunodeficiency after initial immune recoveryDespite > 24 weeks of treatmentConfirmed with at least one subsequent CD4

measurement

Lack of improvement in CD4 cell percentage or absolute count despite >24 weeks of treatment

Rapid rate of decline to or below threshold of age-related severe immunodeficiency

228

Second-Line Regimens

ART sequencing based on resistance patterns associated with specific agents

Goal is to replace failing first-line regimen with a second that has minimal potential for cross resistance

Choices balance potency, toxicity, formulation, and cost

As new data becomes available, these may change

229

Pediatric Second-Line Regimens

AZT or d4T: substitute abacavir (ABC) 3TC: substitute didanosine (ddI) NVP or EFV: substitute lopinavir/ritonavir

(LPV/ritonavir) or if no cold chain available, then nelfinavir

230

Abacavir (ABC)

FormulationOral solution: 20 mg/mlTablets: 300 mg

Can take with or without food Most serious adverse event is acute

hypersensitivity reaction – rare (<3%) but can be fatal

Monitor side effects and toxicityDo not rechallenge if hypersensitivity reaction is

suspected

231

Didanosine (ddI)

Formulation 25, 50, 100, 200 mg tabs10 mg/ml liquid

For proper buffer dose, 2 tabs must be used Administer on empty stomach 1 hour before or 2

hours after meal; don’t take with acidic drinks but can take with waterThis may make administration of regimen difficult, as

drugs may not all be taken together

Monitor side effects and toxicity

232

Lopinavir/ritonavir (Kaletra)

Formulation – dose based on lopinavir Solution: 80/20 mg/mlCapsule: 133.3/33.3 mg

Must take with food Can be stored at room temperature once

dispensed – stable for 60 days Bad taste – can be masked with sweets A very “forgiving” drug Monitor side effects and toxicity

233

Role of the Multidisciplinary Team

Non-clinicians may be the first to hear about a medication toxicity. Their finding need to be communicated to providers who should note patient symptoms/signs in the medical record

Decisions and follow-up should be discussed in multidisciplinary team meetings

Adherence needs to be discussed at every visit and contact (clinician, counselors etc)

234

Patient Education The parent/patient should be aware of what to

expect when starting ART and while receiving ART

The parent/patient should be aware of possible side effects

The parent/patient should know what to do if she believes she is experiencing a side effect (especially if this happens when the clinic is closed)

235

Case Study

A 6 month old baby girl, Mulu, presents to the clinic 12 days after her appointment date

Mother complains her daughter has had a cough and diarrhea for the last 2 weeks

236

Case Continuation

Mother was enrolled in PMTCT program and both baby and mother took Nevirapine

Baby was enrolled at the HIV clinic at 4 weeks and started on Cotrimazole prophylaxis

Exclusively breastfed for 6 months Weaned with no breastfeeding for last 2 weeks Weight gain normal for first 6 months Adherence to care has been poor with mother

missing many appointment dates

237

Case Continuation

Diarrhea has been persistent with loose watery stools passed 6 times each day for the last 2 weeksLittle improvement on oral rehydration therapy

Cough has been progressiveUnresponsive to Amoxicillin

Fever, lethargy and poor feeding File shows 1st DNA PCR was negative

238

Clinical Exam

Vitals: Weight 5.4 kg (1 month ago was 6.4 kg), Temperature 37.8 C

Some wasting present with mild dehydration Child irritable and listless Chest exam finds left sided bronchial breathing Rest of the exam is unremarkable

239

Growth Chart

240

Case Continuation

Chest X-ray showed left lower lobe pneumoniaPrescribe Erythromycin

Oral rehydration therapy for diarrhea Cotrimoxazole prophylaxis Nutritional counseling and advice Multidisciplinary team meeting planned Follow up in 2 weeks

241

Case Continuation

Mother does not return till her 7 month visit Baby’s cough resolved, however diarrhea has

persistedNo fever or vomiting noted

Weight has dropped to 5.2 kg despite mother following nutritional advice

She is adherent to cotrimoxazole Stool studies from previous visit were normal

242

Case Continuation

Clinician is concerned this infant might have HIV and need ART

He sends DNA PCR, CD4, LFTs, CBC and chemistry

Oral rehydration therapy for diarrhea He sends mother for adherence training in

anticipation of starting ART at next visit Cotrimoxazole prophylaxis Nutritional counseling and advice Follow up in 2 weeks

243

Case Continuation

At her next visit her weight is unchanged (5.2Kg) and diarrhea is still present

DNA PCR is positive, CD4% done at 7 months of age is 20%

Baselines tests were within normal Is she eligible for ART?

244

Clinical Question

Considerations for starting ARTIs family appropriately prepared?Does mother understand critical importance of good

adherence?Are there any clinical or laboratory contraindications

to specific drugs?

What ART would you start?

245

Case Conclusion

Adherence counseling done and mother understands importance

She is put on:AZT: 7ml twice a day 3TC: 2ml twice a day and NVP: 2ml once a day

At next visit 1 week later, she has no new complaints and is tolerating her medications

2 weeks later she has gained 500gmSince infant is tolerating medications well escalate the dose

of NVP to 4ml twice a day

246

Summary

ART can provide life sustaining support for the HIV infected child Using clinical staging and CD4 count can help identify the eligible

child In the case of rapidly progressing disease, clinical judgment may

identify the eligible child before diagnosis is confirmed There are unique adherence challenges for children on ART Families need additional support for adherence and frequently

changing dosage requirements A child on ART must be monitored carefully in order to identify

adverse events early and respond appropriately The multi-disciplinary team plays an important role in assessing

adherence and in monitoring the child on ART

Pediatric Adherence

248

Learning Objectives

Identify ways to prepare a family for ARV adherence

List ways to monitor and support ARV adherence

Describe ways to assess adherence

249

Adherence to Treatment: Issues for Children ARV treatment for children requires:

Collaboration between the child and caregiver(s)• Commitment of the caregiver(s)• Cooperation of the child

ARV treatment for children is complicated by:Developmental stage/age of the childParent-child interactionPsychosocial milieuRelatively poor palatability of many pediatric

formulationsCaregiver factors

250

Reported Difficulties Taking ARV Medications, PENTA 5 Taste/Palatability/Volume

Difficulties with unpleasant flavor and/or smellNauseaToo many pills

Social Situations – Fear of disclosureVisiting or out with friendsVisiting relatives over weekendVisitors in houseHad to leave child with a friend for the day

Gibb D et al, Pediatr Infect Dis J 2003:22;56

251

Factors Associated with Adherence

Demographic Variables: age, sex, caregiver type, caregiver sex, income

Disclosure to child, to others Caregiver-child communication Caregiver self-efficacy Caregiver health beliefs Caregiver depression Stress Stigma

252

An Approach to Adherence:Giving Medications to Infants & Children Promoting Adherence

EducationPreparationMonitoringSupport

Assessing AdherenceAssessment MethodsAddressing Barriers

253

Promoting Adherence

1. Education

2. Preparation

3. Monitoring

4. Support

Education

PreparationMonitoring

Support

254

1. Adherence Education

Define adherenceNever missing a dose Keeping to specific times of administrationTaking it the “right” wayLifelong treatment, even when feeling wellUnderscore difficulty of task

Explain importance of strict adherenceUse simple terms, visual aids, analogies

Emphasize need for communication with health care teamTrustPartnershipHonesty

255

2. Adherence Preparation

ARV treatment is rarely an emergency Take time to prepare the child and the caregiver

Personalize medication administration to match the specific aspects of a child’s and family’s life

Address the WHO, WHAT, WHEN and HOW of medication administration. WHO will administer the medications?

• Everyday? Weekdays and weekends? WHAT medications will be given?

• Familiarity with medication WHEN will medications be given?

• Establish specific times and routines HOW will medications be given?

• Details of administration: using syringes or measured spoons, cutting and crushing tablets, with or without food, mixed with beverage, mixed together, sequencing

256

Questions that Help Assess Readiness

Has the mother disclosed HIV status to anyone? Do the other people in the household know about the child’s diagnosis?

Is there support in the household/family? Is the living situation stable? Does the mother understand ARV treatments, dosages, expected

outcomes, potential side effects? Does the mother appreciate the need for intensive monitoring and

follow-up? Does the mother understand the need for strict adherence? Has the child tasted the medications? How does the child’s developmental level influence ability to take

medications? Have the health providers observed medication administration?

257

2. Adherence Preparation (2)

Other preparatory tools for children:Taste testingObservation of dosingTraining for pill swallowingBehavioral reward systemRole playAnticipating problems

• Hypothetical scenarios – What would you do if….vomiting, refusal, fever, other?

258

3. Adherence Monitoring

No perfect measures Emphasize the importance of honest reporting Importance of multidisciplinary approach to

monitoring Provide all possible support as discussed in

adult ART care

259

4. Adherence Support

Lifelong adherence to complex medication regimens is an extremely difficult task!

Identify and reinforce effective, successful strategies Psychosocial support

DisclosureAdherence buddySupport groups

Adherence AidsPill boxesBlister packsCalendarsPre-pouring Labeling syringes

260

What Do You Do When Adherence is Incomplete? Assess why adherence is incomplete Address the barriers to adherence

261

Assessing Incomplete Adherence

Review current regimen Inquire about problems administering

medications – obtain a descriptive assessment

Review WHO, WHAT, WHEN, HOW Observe administration

262

Addressing Adherence Barriers: What to Do Next Identify specific barriers to adherence

Consider stopping current regimen

Address specific barriers to adherence Alter current regimen or change to new regimen

Formulation or single drug substitutionNew regimen in the case of treatment failure

Begin againAdherence educationAdherence preparationAdherence monitoring Adherence support

263

Adherence Fatigue

Do not assume “once adherent, always adherent”

It can be anticipated that with time: Children may tire of taking medicationsCaretakers may tire of administering/supervising

medicationProviders may tire of monitoring/supporting

adherence

Beware of adherence fatigue!

264

Case 1: Kebede

Kebede is a 2.5 year-old boy who has been enrolled in the clinic since birth

He began ZDV + 3TC + NVP at 6 months of age when he was diagnosed with pneumonia and failure-to-thrive. He has done very well on this regimen

265

Kebede’s Current Medications

ZDV 15cc every 12 hours 3TC 6cc every 12 hours NVP 10cc every 12 hours Cotrimoxazole 10cc every morning MVI 1 cc every morning

266

Kebede

Alem, Kebede’s mother, reports that lately she has been having trouble giving him medication. In the past he has always taken the ARV treatment easily, but over the last several months it hasn’t gone well

What questions should you ask Alem?

267

Questions for Alem

Who gives the medicine? All the time? Which medications is he getting? What happens when Alem tries to give him his

medication –what does Kebede do? Does he 1) refuse; 2)vomit, spit, choke; 3)run away? Does this happen all of the time or some of the time? Is it one drug in particular or all of the drugs? How long does it take to give him his medication? Has he missed any of this doses? All of the

medications or just one? Has Alem found anything that helps to give his meds? Other?

268

Kebede

Alem reports that he doesn’t like the ZDV. He runs from her when she tries to give him his medications. She must capture him, hold him down, force his mouth open to take the ZDV. He then gags and chokes, often vomiting the medicine

He takes the NVP and 3TC, but sometimes she thinks he doesn’t keep them down either. Alem, having learned the importance of adherence, is worried

What do you need to know to begin to determine the cause of Kebede’s behavior?

269

Possible Reasons for Kebede’s Behavior Change New developmental stage

Increasing emotional and physical independence, “terrible twos”

Changes in householdChange in scheduleNew changes in caretakerNew members of household

Adherence fatigue Other What do you need to do now?

270

Incomplete Adherence: What to do Next?

Identify specific barriers to adherenceObserve medication administration and parent-child interaction

Address specific barriers to adherenceOffer explanation for Kebede’s change in behavior Alter current regimen or change to new regimen

• Formulation or single drug substitution• New regimen in the case of treatment failure

Begin again with adherence• Education• Preparation• Monitoring • Support

271

Kebede

You feel that the problem is probably related only to the ZDV and may require a change or alteration in the regimen

Since Alem understands the importance of adherence and is committed to Kebede taking all of his medications, you begin to discuss options with her

What are some possible solutions?

272

Other Ways to Give Kebede Medications Consider behavioral interventions

Reward system

Explore ways to mask tasteMix with liquidsMix medications togetherTasty “chaser”

Explore other formulationsCrushed tablet if dosing appropriate

Other?

273

Kebede: Conclusion

Dosing: You look at the dosing guidelines brochure for each of

Kebede’s medicationsEach ZDV capsule = 100mgTogether with Alem you decide to change the ZDV to

2 capsules twice daily Follow up

Alem & Kebede return 2 weeks later. Alem reports success giving Kebede crushed tablets (She crushes and mixes the tab with sweet pudding) and he takes it willingly

274

Summary: Adherence to ARV for Children

There are multiple barriers to adherence Successful adherence requires

Education and preparation before starting treatmentAssessment and monitoring during treatment

Most families will have periods of time when adherence is incompleteBarriers to adherence should be assessed and

addressed at each clinic visit

Providers and families may experience adherence fatigue

275

Summary

Adherence for children Involve the child as well as one or more adultsPay attention to:

• Age, developmental stage, feelings, health status of the child

• Beliefs and feelings of the caregivers• Family dynamics

Adherence for children should be viewed as ongoing processes requiring: Systematic approachVaried skills held in multidisciplinary teams

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