View
37
Download
1
Category
Tags:
Preview:
DESCRIPTION
Citation preview
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
USAID APHIA IINAIROBI/CENTRAL
USAID APHIA IINAIROBI/CENTRAL
HIV in Children
Unit 1: Epidemiology and HIV transmission in ChildrenUnit 2: Natural history of HIV in Children Unit 3: Diagnosis and Staging of HIV in ChildrenUnit 4: HIV – Related Conditions: Prevention and
TreatmentUnit 5: Antiretroviral Therapy in Children
USAID APHIA IINAIROBI/CENTRAL
Objectives
• To outline the epidemiology of HIV in children• To describe various modes of HIV transmission to children.• To discuss the natural disease progression of HIV in children.• Outline diagnostic criteria for paediatric HIV – laboratory as well as
clinical.• To impart knowledge on prevention and treatment of common HIV
related conditions in HIV infected children• To describe how and when to provide antiretroviral therapy in
children, , including initiation, pre-ART preparation, monitoring, when to change/withdraw ART.
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
Unit 1 Epidemiology and HIV transmission in Children
USAID APHIA IINAIROBI/CENTRAL
Objective of Unit 1
• To outline the epidemiology of HIV in children• To describe various modes of HIV transmission to
children.
USAID APHIA IINAIROBI/CENTRAL
Epidemiology - Kenya
• 1 million live births in Kenya annually• 8% born to HIV infected mothers• Without PMTCT 30% of these become infected• About 24,000 neonates acquire HIV annually• About 12,000 (50%) die within first 2 years• HIV has had a negative impact on infant survival
USAID APHIA IINAIROBI/CENTRAL
Modes of HIV transmission in Children
• Mother to child transmission-95%• Sexual –Adolescent, abuse• Transfusion of infected blood• Unsterile injection procedure (2.5% in adults as
well as children)• Scarification and other traditional practices
USAID APHIA IINAIROBI/CENTRAL
Modes of HIV transmission to Children
• Mother to child transmission – 95% of paediatric infections– Intrauterine– During delivery– During breastfeeding
USAID APHIA IINAIROBI/CENTRAL
Mother to Child HIV Transmission
30% babies born to HIV+ womenbecome infected through MTCT
5% intrauterine
10-20% during delivery
10-20% via breastfeeding
USAID APHIA IINAIROBI/CENTRAL
Modes of HIV transmission to Children
• Horizontal transmission - < 5% of paediatric infections– Sexual transmission– Transfusion of blood and blood products– Exposure to other body fluids– Use of contaminated needles and other skin
piercing/cutting instruments (circumcision, uvulectomy).
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
Unit 2: Natural history of HIV in Children
USAID APHIA IINAIROBI/CENTRAL
Objective of Unit 2
• To discuss the natural disease progression of HIV in children.
• Outline diagnostic criteria for paediatric HIV – laboratory as well as clinical.
USAID APHIA IINAIROBI/CENTRAL
Natural history – patterns of disease progression in African children
HIV disease progresses at differing rates in children• Rapid progressors (25 – 30%):
– Develop AIDS and die within 1 year. – Disease acquired in-utero or perinatally.
• Intermediate progressors (50 – 60%):– Children who develop symptoms early in life.– Deteriorate and die by 3 to 5 years.
• Slow progressors (5 – 25%):– Long-term survivors who live beyond 8 years of age.
USAID APHIA IINAIROBI/CENTRAL
Natural history – patterns of disease progression in African children
• Slow Progressors
– Low viral loads at birth
– Stable CD4 counts for 2-10 years slow declinethen
– Growth stunting
– Opportunistic infections after 2-10 years as disease progresses
– Encephalopathy rare, growth stunting common
• Rapid Progressors– High viral load at birth
– Rapidly declining CD4
– Low Birth Weight
– Chronically unwell first year• Persistent or recurrent diarrhea• Recurrent bacterial and fungal
infections• Severe encephalopathy before
18 months
USAID APHIA IINAIROBI/CENTRAL
Natural History – Immunological changes
Immunologic Parameters
• Absolute CD4 count higher in healthy children than in adults.
• Absolute CD4 count slowly decline to adult levels by age 6
• CD4 percentage does not change with age.
• In children < 6 yr CD4 percentage is the preferred immunological parameter for monitoring disease progression.
USAID APHIA IINAIROBI/CENTRAL
Natural History – Immunological changes
Age-related Decrease in CD4+ Number
0
2000
4000
6000
Age in Months
CD
+ N
umbe
r/m
m3
5th percentile
95th percentile
4 12 24 6090
USAID APHIA IINAIROBI/CENTRAL
Natural History – Immunological changes
Age-related Decrease in CD4+ Percentage
0
20
40
60
80
Age in Months
CD
4+
% 5th percentile
95th percentile
4 12 24 6090
USAID APHIA IINAIROBI/CENTRAL
Natural History – Viral load patterns in children
The HIV viral load (RNA) pattern in perinatally infected infants differs from infected adults.
In infants Viral load (RNA levels):• Increase to high levels >100,000 to millions of copies/ml by
2 months of age.• Remain high through outthe first year of life.• Decline slowly over the next few years to eventually achieve
a “set point” after age 5 years.
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
Unit 3 Diagnosis and Staging of HIV in Children
USAID APHIA IINAIROBI/CENTRAL
Diagnosis and Staging of Paediatric HIV -scope
• I: Clinical presentation of Paediatric HIV• II: Diagnosis:
– Clinical diagnosis – Laboratory diagnosis
• III: Staging– Clinical staging– Immunological staging
USAID APHIA IINAIROBI/CENTRAL
I: Clinical presentation of HIV in Children
• Understand common clinical presentations of progressive paediatric HIV infection
• Compare between common paediatric conditions and clinical signs of paediatric HIV
USAID APHIA IINAIROBI/CENTRAL
Clinical suspicion of HIV
• First do an initial clinical assessment of child and suspect HIV,
• Certain clinical conditions, if present, point to high probability of HIV infection in the child
USAID APHIA IINAIROBI/CENTRAL
Clinical signs & conditions suggestive of HIV infection in a child (1)
• Oesophageal candidiasis• Herpes zoster (shingles) • Invasive salmonella infection• Pneumocystis jiroveci pneumonia (PCP)• Extrapulmonary cryptococcosis• Lymphoma• Kaposi’s sarcoma
USAID APHIA IINAIROBI/CENTRAL
Clinical signs & conditions suggestive of HIV infection in a child (2)
• Recurrent severe bacterial infection• Persistent or recurrent oral thrush• Parotid enlargement• Generalized lymphadenopathy• Hepatosplenomegaly (non-malaria areas)• Persistent or recurrent fever• Neurologic dysfunction• Persistent generalized dermatitis
USAID APHIA IINAIROBI/CENTRAL
Clinical signs & conditions Common in both HIV+ and HIV- children
• Otitis media - persistent or recurrent• Diarrhoea – persistent or recurrent• Severe pneumonia• Tuberculosis• Failure to thrive
USAID APHIA IINAIROBI/CENTRAL
Entry points for HIV diagnosis
HIV exposed &/or infected children can be identified by actively seeking to test them in health services where they and their parents seek care.
• Sick children services• PMTCT clinics• MCH clinics• TB clinics• Adult HIV clinicsHIV positive parents should be encouraged to bring all their children in
for testingConfirmation of HIV diagnois provides an entry point for appropriate care
for the child and the family.
USAID APHIA IINAIROBI/CENTRAL
IMCI definition of symptomatic HIV infection
Presence of 3 or more of the following:• TB in any parent in the last 5 years• Pneumonia (now or previously)• 2 or more episodes persistent diarrhoea (>14 days)• Growth faltering or weight < 3rd centile
(below “very low weight curve” in card• Enlarged lymph nodes in 2 or more of the following sites
(neck, axilla, groin)• Oral thrush
USAID APHIA IINAIROBI/CENTRAL
DIAGNOSIS OF PEDIATRIC HIV
USAID APHIA IINAIROBI/CENTRAL
Laboratory Diagnosis
There are two types of laboratory tests for HIV diagnosis:
Antibody tests-detect antibody toHIVVirologic tests-detect HIV virus or antigen
USAID APHIA IINAIROBI/CENTRAL
Laboratory DiagnosisChild >18 months
Child > 18 months:• A positive HIV antibody test confirms HIV
infection as maternal antibodies have cleared
• A negative HIV antibody test rules out HIV infection in non breast feeding child
USAID APHIA IINAIROBI/CENTRAL
Laboratory DiagnosisChild < 18 months
Child < 18 months, HIV Antibody (Ab) may come from:• Maternal Ab passively transferred to infant
– Maternal Ab may persist in her infant up to 18 months– Ab test is +ve in ALL children born to HIV+ women, including those
that are NOT infected (gives false +ve results)• Infant generated Ab if infant is HIV infected.
A positive HIV Ab test at this age is therefore not diagnostic, only shows child has been HIV exposed
USAID APHIA IINAIROBI/CENTRAL
Laboratory DiagnosisVirologic tests
Virologic test – detect HIV virus in bloodIs ideal method of HIV diagnosis in child under 18 months
• Various types:- RNA PCR - most available, also gives viral load- DNA PCR – not widely available- P24 antigen (immune-complex dissociated)
• When to do virologic test:– Not BF: test at age 1 month repeat 3 months later– BF: wait until 3 months after cessation of BF to confirm final HIV
status.
USAID APHIA IINAIROBI/CENTRAL
When to do PCR for HIV diagnosis of Child < 18 months
• 30 % become infected through MTCT– 5 % intrauterine-PCR +ve in first week of life– 15% during delivery-PCR +ve by age 1 month– 10% via breast feeding-Do PCR 1 month after
stopping breast feeding
USAID APHIA IINAIROBI/CENTRAL
When to do PCR for HIV diagnosis of child <18 months
• If child NOT breast feeding:– Do PCR from 4 to 6 weeks, repeat after 3 month
• If child IS breast feeding:– Do PCR from age 1 month
• If positive at 1 month, encourage mother to continue BF• If negative, encourage mother to consider stopping BF early (IF
REPLACEMENT FEEDING IS AFFORDABLE, ACCESIBLE, FEASIBLE, SAFE AND SUSTAINABLE)
USAID APHIA IINAIROBI/CENTRAL
Interpretation of laboratory diagnosis
• Diagnostic Gold standard- is to perform two tests to confirm or rule out HIV infection
• 2 positive virological tests performed on blood samples taken on 2 separate dates confirms HIV infection.
• 2 or more negative virological tests at age >1 month, one of which is performed at age >4 months in a non- breastfed infant rules out HIV infection.
• Remember, if breast feeding wait 1 month after cessation of breastfeeding.
USAID APHIA IINAIROBI/CENTRAL
HIV Diagnosis before age 18 month without virologic test
• The infant is confirmed as being HIV antibody-positive• Diagnosis of any AIDs-indicator can be made
or• The infant is symptomatic with two or more of the following:
– Oral candidiasis /thrush– Severe pneumonia– Severe sepsis
Other factors supporting HIV infection in infant include:– recent maternal death or advanced HIV disease in mother. – CD% <20%
Confirmation of the diagnosis of HIV infection should be sought as soon as possible.
USAID APHIA IINAIROBI/CENTRAL
DIAGNOSIS - summary
• In children < 18 months HIV is diagnosed by 2 positive virological tests performed on blood samples taken on 2 separate dates.
– HIV is excluded by 2 or more negative virological tests at >age 1 month, one of which is performed at age >4 months in a non-breastfed infant
– If BF wait 3 months after cessation of BF
• Antibody tests: 2 or more antibody tests after 18 months confirm or exclude diagnosis.
• Presumptive severe HIV infection Child who needs ART should be made where PCR is not available and HIV diagnosis should be confirmed as soon a spossible or at age of 18 months
USAID APHIA IINAIROBI/CENTRAL
STAGING PEDIATRIC HIV
Clinical and Immunological
USAID APHIA IINAIROBI/CENTRAL
Clinical Staging
TWO international clinical staging systems:
World Health Organization (WHO)Four stages – 1, 2, 3, 4
Centres for Disease Control (CDC)Four stages – N, A, B, C
USAID APHIA IINAIROBI/CENTRAL
Clinical Staging
Stage WHO CDC
Asymptomatic 1 N
Mild 2 A
Moderate 3 B
Severe (AIDS) 4 C
USAID APHIA IINAIROBI/CENTRAL
WHO Clinical Staging – stage 1
Stage I• Asymptomatic• Persistent generalized lymphadenopathy (PGL)
USAID APHIA IINAIROBI/CENTRAL
WHO Clinical Staging - stage 2
• Papular pruritic eruptions• Seborrheic dermatitis• Fungal nail infections• Angular cheilitis• Linear gingival erythema• Extensive HPV or molluscum infection (>5% of body area/face)• Recurrent oral ulcerations (>2 episodes/g mos)• Parotid enlargement• Hepatosplenomegaly • Herpes zoster (>1 episode/12 mos)• Recurrent or chronic upper respiratory infection (URI): otitis media,
otorrhea, sinusitis (>2 episodes/6 mos)
USAID APHIA IINAIROBI/CENTRAL
USAID APHIA IINAIROBI/CENTRAL
WHO Clinical Staging – Stage 3
• Unexplained moderate malnutrition (-2SD or Z score) not responding to standard therapy
• Unexplained persistent diarrhea (>14 days)• Unexplained persistent fever (intermittent or constant, >
1mo)• Oral candidiasis (outside neonatal period)• Oral hairy leukoplakia• Pulmonary tuberculosis, TB lymphadenitis• Severe recurrent presumed bacterial pneumonia
USAID APHIA IINAIROBI/CENTRAL
USAID APHIA IINAIROBI/CENTRAL
WHO Clinical Staging – Stage 3 (continued)
• Acute necrotizing ulcerative gingivitis/periodontitis• Lymphoid interstitial pneumonitis (LIP)• Unexplained anemia (<8g/dL), neutropenia
(<1000/mm3), or thrombocytopenia (<30,000/mm3) for >1 mo.
• HIV-related cardiomyopathy• HIV-related nephropathy
USAID APHIA IINAIROBI/CENTRAL
WHO stage 4 – all ages
Conditions where a presumptive diagnosis can be made using clinical signs or simple investigations:
• Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy
• Pneumocystis pneumonia• Recurrent severe presumed bacterial infections (2 or > episodes within one year
e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia )
• Chronic orolabial or cutaneous Herpes simplex infection (of more 1 month duration)• Extrapulmonary tuberculosis (except TB adenitis)• Kaposi's sarcoma• Oesophageal Candida • CNS Toxoplasmosis • HIV encephalopathy
USAID APHIA IINAIROBI/CENTRAL
WHO stage 4 – all ages (continued)
Conditions where confirmatory diagnostic testing is necessary:• CMV infection (CMV retinitis or infection of organ other than liver, spleen,
or lymph nodes onset at age 1 month or more) • Cryptococcal meningitis (or other extrapulmonary disease)• Any disseminated endemic mycosis(e.g. extra-pulmonary Histoplasmosis,
Coccidiomycosis, Penicilliosis)• Cryptosporidiosis • Isosporiasis• Disseminated non-tuberculous mycobacteria infection • Candida of trachea, bronchi or lungs• Acquired HIV related recto-vesico fistula
USAID APHIA IINAIROBI/CENTRAL
WHO-Presumptive severe HIV infection: Child < 18 months requiring ART- when PCR testing not available
• The infant is confirmed as being HIV antibody-positive• Diagnosis of any AIDs-indicator can be made
or• The infant is symptomatic with two or more of the following:
– Oral candidiasis /thrush– Severe pneumonia– Severe sepsis
Other factors supporting HIV infection in infant include:– recent maternal death or advanced HIV disease in mother. – CD% <20%
Confirmation of the diagnosis of HIV infection should be sought as soon as possible.
USAID APHIA IINAIROBI/CENTRAL
Exercise on clinical staging
• Case 1:• Tooto is 4 yrs old, presents with oral thrush,
recurrent pneumonia, fever for 2 weeks, and weighs 14kgs.
• Qtn: Whatis Toto’s WHO clinical stage?
USAID APHIA IINAIROBI/CENTRAL
Exercise on Clinical Staging
• ANSWER: WHO stage 3 based on the oral thrush and recurrent pneumonia.
USAID APHIA IINAIROBI/CENTRAL
Exercise on Clinical Staging
• Case 2:• Abba is 10 months and presents with severe oral thrush
and sepsis requiring one month hospitalization. She recently lost her mother. There is no PCR available for virological diagnosis but her HIV antibody test is positive.
• Qtn: What is her WHO clinical stage?
USAID APHIA IINAIROBI/CENTRAL
Exercise on Clinical Staging
• Answer: We make a presumptive HIV stage 4 clinical diagnosis in this child based on her positive HIV ELISA and recent death of her mother.
• She is presumptive stage 5 based on age less than 18 months, oral thrush and severe sepsis.
USAID APHIA IINAIROBI/CENTRAL
Immunological Staging
Differences in CD4 counts between adults and children
• CD4 counts are normally high in healthy young children
• Decline to adult levels by age 6 years• CD4% dose not change with age
USAID APHIA IINAIROBI/CENTRAL
Indicators of severe Immunosuppresion (WHO 2006)
Severe immuno-suppression
< 12 months 12-35 months 36-59 months 5yr+
By CD4% <25% <20% <15% <15%
By CD4 count <1500 <750 <350 <200
By total lymphocyte count
<4000 <3000 <2500 <2000
USAID APHIA IINAIROBI/CENTRAL
NASCOP 2007- classification of severe immunosuppresion in children
• WHO proposed immune staging 2006 more complex than previous immune staging
• To maintain simplicity and continuity NASCOP opted to retain three age-group classification (<18 months, 18 months-5 years and above 5 years) when making ART decisions for ART initiation in children
USAID APHIA IINAIROBI/CENTRAL
Immunological Staging Using CD4 percentage
Severe immunosuppression
< 18 monthsCD4 %
18 months-59 monthsCD4 %
> 5 years (60 months)CD4 %
By CD4%<25 % <20% <15%
By CD count< 1500 < 500 <250
USAID APHIA IINAIROBI/CENTRAL
Total Lymphocyte Count (TLC)
• Where one cannot perform CD4 assays, TLC provides a rough guide to level of immunosuppression.
• As CD4 count drops, TLC also drops• Only useful for baseline evaluation for
immunosuppression.
USAID APHIA IINAIROBI/CENTRAL
Computing Total Lymphocyte Count
TLC = Lymphocyte percentage per litre x 100 White cell count per litre
TLC = Lymphocyte percentage per mm3 x 100 White cell count per mm3
USAID APHIA IINAIROBI/CENTRAL
Computing Total Lymphocyte Count
• If Total WBC =4.0 X 109/litre and differential Lymphocyte count is 50%, What is the total lymphocyte count?
(Give the TLC in two different units – per litre and per mm3).
USAID APHIA IINAIROBI/CENTRAL
Computing Total Lymphocyte Count
AnswerTLC = 50% of 4.0 x 109
i.e. 2.0 x 109/litre.
Divide by 106 to convert TLC to per mm3
Above example, TLC = (2.0 x 109) 106 = 2000/mm3
USAID APHIA IINAIROBI/CENTRAL
Computing CD4%
CD4% = Absolute CD4 count per mm3 x 100 Total lymphocyte count per mm3
OR = Absolute CD4 count per litre x 100 Total lymphocyte count per litre
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
Unit 4 HIV – Related Conditions:Prevention and Treatment
USAID APHIA IINAIROBI/CENTRAL
Diagnosis – combining lab and clinical criteria
• May not have access to PCR as is not widely available or affordable.
• You can still make a diagnosis in child < 18 months combining simple lab and clinical parameters.
USAID APHIA IINAIROBI/CENTRAL
Summary of approach to diagnosis
1. Do clinical assessment-suspect HIV2. Do clinical staging (WHO)3. Do HIV test-<18 months-PCR, >18 months-antibody test4. Do CD4 test5. If Cd4 Not available, do Total Lymphocyte Count (TLC)6. Make final diagnosis and stage child’s disease
USAID APHIA IINAIROBI/CENTRAL
Unit 4: HIV related conditions
• OBJECTIVE: To impart knowledge on prevention and treatment of common HIV related conditions in HIV infected children
USAID APHIA IINAIROBI/CENTRAL
HIV-related Diseases
Infections that complicate HIV disease in children include:
• Infections that are commonly seen even in HIV uninfected children
• Opportunistic infections – rare in HIV negative children – more common with advancing immune compromise.
USAID APHIA IINAIROBI/CENTRAL
HIV-related Diseases (cont)
• Other clinical problems not commonly seen in other children– Lymphoid interstitial pneumonitis– Malignancies– HIV encephalopathy
USAID APHIA IINAIROBI/CENTRAL
Respiratory Infections in HIV infected children
• Respiratory infections are the most common causes of hospital admissions
• Aetiology mainly S. pneumoniae, H. influenzae, non- typhoid Salmonella– These pathogens are also the common causes of bacteraemia and
meningitis in children with HIV.• Treatment is the same as in HIV negative children but duration
may need to be longer.• Prevention
– Immunization – pneumococcal vaccine – Cotrimoxazole
USAID APHIA IINAIROBI/CENTRAL
Infections causing diarrhoea in HIV infected Children
• Acute, persistent and chronic diarrhoea are important causes of morbidity in children with HIV
• Etiologies include organisms commonly seen in HIV negative children as well as opportunistic pathogens.– Rotavirus– E coli– Samonella– candida
USAID APHIA IINAIROBI/CENTRAL
Infections causing diarrhoea in HIV infected children
• Opportunistic pathogens.– Cryptosporidium– Microsporidium– Isospora belli– Cytomegalovirus (CMV)– Herpes simplex virus (HSV)
USAID APHIA IINAIROBI/CENTRAL
Measles
• Severe illness in children with HIV infection, particularly those with advanced immunodeficiency
• May occur in early infancy in HIV infected children
• Severe cases can occur without the typical rash and may be complicated by pneumonia or encephalitis.
• High case fatality, should be treated in hospital.
USAID APHIA IINAIROBI/CENTRAL
Measles
• Management should include 2 doses of vitamin A calculated based on the age of the child– 50,000 IU if aged <6 months; 200,000 IU in children
aged 12 months to 1 year• Immunization should be given to HIV infected
children at 6 months and repeated at 9 months.
USAID APHIA IINAIROBI/CENTRAL
Septicemia and Meningitis
• Fever may be the only presenting symptom of serious infection
• HIV infected children with fever need careful clinical and laboratory assessment to identify the cause of fever, and intensive follow-up
• Treatment should follow local guidelines• Treatment failure is more frequent.• Prevention: immunisation (Hib, pneumococcal)
USAID APHIA IINAIROBI/CENTRAL
Skin infections
• Bacterial – impetigo, cellulitis, abscess
• Fungal skin infections; more common, extensive and more difficult to treat, than in the non immunocompromised.
• Viral –molluscum contagiosum.
• Parasites - scabies
USAID APHIA IINAIROBI/CENTRAL
Multiple skin
abscesses
Photo courtesy of
Israel Kalyesubula
USAID APHIA IINAIROBI/CENTRAL
Malaria
• May be associated with more severe disease with HIV infected children due to:
• Pre-existing anaemia• Malnutrition• Low immunity• Co-morbidity – septicaemia
USAID APHIA IINAIROBI/CENTRAL
Summary
Characteristics of common childhood infections in HIV infected children:
• Same pathogens as non HIV-infected children• Severe Disease• Recurrence• Higher case fatality rates
USAID APHIA IINAIROBI/CENTRAL
Opportunistic Infections
• Prevalence and severity of opportunistic infections increase with HIV disease progression
• Often occult and non-localizing• Unusual organisms• Unusual presentation
USAID APHIA IINAIROBI/CENTRAL
Prevention of Opportunistic Infections
• The two broad strategies for prevention include chemoprophylaxis and immunization.
USAID APHIA IINAIROBI/CENTRAL
Immunization of HIV Infected Child
Broad issues in the immunosuppressed child:• Some live vaccines can result in severe vaccine
associated disease- BCG• Immune response to vaccines may be reduced• Immune response may not be sustained
USAID APHIA IINAIROBI/CENTRAL
World Health Organization/UNICEF recommendations
For the Immunization of HIV-infected children and women of childbearing age
USAID APHIA IINAIROBI/CENTRAL
Vaccine Asymptomatic HIV Symptomatic HIV
Optimal timing of immunization
BCG Yes No Birth
DPT Yes Yes 6,10,14 wks
OPV* Yes Yes 0, 6,10,14 wks
Measles Yes Yes 6 and 9 months
Hepatitis B Yes Yes As for uninfected children
Yellow fever Yes No**
* IPV an alternative for children with symptomatic HIV** Pending further studies
WHO/UNICEF Recommendations for HIV Infected Children
USAID APHIA IINAIROBI/CENTRAL
Immunization of HIV infected infants
• Use National immunization guidelines (KEPI guidelines)• Measles give 1st dose at 6 months; repeat at 9 months whether
symptomatic or not• BCG and Yellow fever vaccines: contraindicated in full blown
AIDS
• Avoid missed opportunities for HIV infected children who are sick
USAID APHIA IINAIROBI/CENTRAL
Chemoprophylaxis
This involves administering daily an antimicrobial drug to prevent disease by specific opportunistic organisms:
• Given against PCP, TB and Cryptococcosis• Aim of chemoprophylaxis includes
– Primary prevention: prevention of the first episode– Secondary prevention: prevention of recurrence after an initial
episode of an opportunistic infection
USAID APHIA IINAIROBI/CENTRAL
TB Chemoprophylaxis
This should be given to the following:• Neonate whose mother is diagosed with PTB
• All contacts under 5 years of age in a household with an adult with open TB– Need to first exclude active TB disease in the child.
INH 5-10mg/kg/day for 6 months
USAID APHIA IINAIROBI/CENTRAL
Pneumocystis Pneumonia
• Caused by a fungus, Pneumocystis jiroveci*, that is commonly found in the environment
• Commoner under the age of 1 year and in severely immunosuppressed children
• Major cause of morbidity and mortality in HIV infected children• Clinical presentation:
Tachypnoea– Dyspnoea– Low grade fever or afebrile– Cough– Hypoxemia (paO2 < 90%)– Clear chest or fine crepitations– Poor response to standard antibiotics
USAID APHIA IINAIROBI/CENTRAL
Investigations
• Chest X-ray: hyperinflation, diffuse infiltrates or may be normal
• Sputum induction or nasopharyngeal aspirate: stain with Silver or Immunofluorescent stain
• Bronchoalveolar lavage: bronchial wash specimen stain as above
• Diagnosis should be made clinically and empirical treatment should be started
USAID APHIA IINAIROBI/CENTRAL
Management of PCP
• Supportive – Oxygen/ventilatory support– Maintain and monitor hydration– Nutritional support– Continue therapy for bacterial pneumonia
• Definative treatment – Co-trimoxazole
USAID APHIA IINAIROBI/CENTRAL
PCP Treatment
• Cotrimoxazole I.V (or oral if IV not available)– Trimethoprim (TMP): 15-20 mg/kg/day in 3-4 doses– Sulphamethoxazole (SMX): 75-100 mg/kg/day in 3-4 doses
• Infuse each dose over 1 hour • After acute symtoms subside, change from I.V. to oral• If I.V. formulation not available, give oral form
– Duration of treatment: 3 weeksOR
• IV Pentamidine 4mg/kg/day OD x 21 daysAdd prednisone 2mg/kg for 7-14 days in severely ill children (taper off)
USAID APHIA IINAIROBI/CENTRAL
PCP Prophylaxis
• Co-trimoxazole prophylaxis– All HIV exposed infants until HIV infection excluded– All HlV infected children– All children who are possibly HIV infected as per IMCI
guidelines• Dose 25mg SMX / 5mg TMP per kg O.D. (30mg
cotrimoxazole/kg o.d.)
OR• Dapsone 2mg/kg p.o daily
USAID APHIA IINAIROBI/CENTRAL
Cotrimoxazole reaction and management
USAID APHIA IINAIROBI/CENTRAL
Candidiasis
• Oral candidiasis a frequent OI• May extend to oesophagus and disseminate
when CD4 severely depressed• Oesophageal candidiasis assoc with difficulty in
swallowing/dysphagia
USAID APHIA IINAIROBI/CENTRAL
USAID APHIA IINAIROBI/CENTRAL
Treatment of Candidiasis
Oral thrush:• Clotrimazole mouth paint 10-20 drops p.o qid 7 days (after
feeds) or until thrush clears.• Or clotrimazole 10 mg troches (older children only) Or:• 0.25%-0.5% gentian violet solution • 2% miconazole gel, 2.5 ml (young child) or 5 ml (older
child) two times a day
USAID APHIA IINAIROBI/CENTRAL
Treatment of Candidiasis
Oesophageal candidiasis:• Oral ketoconazole , 3-6mg/kg/day for 7 days OR• Oral fluconazole 3-6 mg/kg/day for 2-3 weeks or
until resolution of symptoms.
USAID APHIA IINAIROBI/CENTRAL
Photo courtesy of Israel Kalyesubula
USAID APHIA IINAIROBI/CENTRAL
USAID APHIA IINAIROBI/CENTRAL
Coccidioidomycosis
USAID APHIA IINAIROBI/CENTRAL
Katindi – 6 years
Full blown AIDSWeight 14kg, height 90cmStarted on co-trimoxazole 5 ml once daily
Q1 Is the dose appropriate?
USAID APHIA IINAIROBI/CENTRAL
Katindi
• Katindi developed severe Steven Johnsons reaction to the cotrimoxazole
Q 2 How will you manage her?Q3 After stabilized, how is it possible to
continue to give her prophylaxis against PCP?
USAID APHIA IINAIROBI/CENTRAL
Katindi
While you are deciding what to do about her prophylaxis, she presents in casualty with
• Severe cough of 1 weeks duration• Afebrile, Cyanosis• RR 90/min• Clear chest
Q4 What is the diagnosis?Q5 How will you treat her?
USAID APHIA IINAIROBI/CENTRAL
Management of HIV infected Children
Unit 5 Antiretroviral Therapy in Children
USAID APHIA IINAIROBI/CENTRAL
Unit 5 Antiretroviral Therapy in Children• Objective: To describe how and when to provide antiretroviral therapy in children, , including initiation, pre-ART preparation, monitoring, when to change/withdraw ART.
USAID APHIA IINAIROBI/CENTRAL
Antiretroviral Therapy
Will cover the following:• Indications for ART initiation• National ART Regimens• Monitoring• Indications for change or withdrawal of ART• National second line regimens• ART and tuberculosis
USAID APHIA IINAIROBI/CENTRAL
Criteria for ART Initiation
There are two broad criteria to consider prior to ART initiation
• Medical criteria
• Psychosocial criteria
USAID APHIA IINAIROBI/CENTRAL
Criteria for ART Initiation
Medical criteria• WHO stage 3 or 4 disease (irrespective of CD4 counts or %).• Low CD4 count or percentage as follows (irrespective of WHO stage):
– Child < 18 months – CD4 < 25% or absolute CD4 count < 1500– Child 18 months to 5 years – CD4 < 20% or absolute CD4 count < 500– Child older than 5 years – CD4 < 15% or absolute CD4 count < 250
• Recurrent hospitalizations (> 2 admissions in previous year) for HIV-related disease, or prolonged hospitalization (> 4 weeks) in previous year.
USAID APHIA IINAIROBI/CENTRAL
Criteria For ART Initiation
Psychosocial criteria• An identifiable parent or guardian who is able to understand the
regimen, and consistently administer the child’s medication.• Adolescent – disclosure of HIV diagnosis before ART initiation
recommended where possible• Ability to regularly attend the HIV clinic appointments.• Sustainable long-term access to antiretroviral drugs (either
through programs providing ART, or financially able to purchase ARV drugs).
USAID APHIA IINAIROBI/CENTRAL
Preparing a Child for ART
Prior to initiating ART, the following preparations should take place
• Medical Preparation
• Counseling Preparation
USAID APHIA IINAIROBI/CENTRAL
Preparing a Child for ART (2)
Medical Preparation• Baseline tests to check haematological, liver and kidney
function:– Full blood count (resources limited, do Hb)– Liver function tests (resources limited, do alanine transaminase
or ALT)– Renal function tests (resources limited, do serum creatinine)
• Do baseline CD4 if possible• Do baseline viral load (RNA PCR – this is optional if
resources limited)
USAID APHIA IINAIROBI/CENTRAL
Preparing a Child for ART (3)
Medical Preparation (continued)• Baseline clinical assessment including weight, height,
surface area.• If current TB suspected, investigate for TB (If TB
confirmed, consider delaying ART initiation until child completes 2-4 weeks of anti TB treatment)
• Initiate co-trimoxazole prophylaxis • Treat any inter-current illnesses
USAID APHIA IINAIROBI/CENTRAL
Prior to starting ARV in children
Start in haste, repent at leisure!!Starting ART is never an emergencyTake time to counsel, prepare, educate the familyCounsel the caregiver on:• Cost – drugs, monitoring tests, food security• Adherence to therapy – strict time scheduling• Support, support, support. Child can’t do it alone.• Older child – disclosure to child• Goals, limitations and side effects of ARTDo careful social assessment of family situation prior to starting
therapy.
USAID APHIA IINAIROBI/CENTRAL
Prior to starting ARV in children- cont..
• When and how to administer the drugs• Possible adverse effects and how to recognize and deal with
them• Possibillity of immune reconstitution inflammatory syndrome
(initially getting worst before getting better)
• Donot overemphasize the last two issues-Don't scare guardian
USAID APHIA IINAIROBI/CENTRAL
Goals of ARV Therapy
• Maximal and durable suppression of HIV replication.
• Restoration and preservation of immune function.
• Reduce HIV related Morbidity & Mortality.• Improve quality of life.
USAID APHIA IINAIROBI/CENTRAL
Special Considerations for Children and ARVs
Choose drugs that:• Do not have to be timed around meals• Have acceptable taste• Suspensions/syrups are stable at room temperature if patient
does not own a refrigerator. • Children older than 6 years may take tablet and capsule
formulations• Some capsule formulations may be opened and capsule content
mixed with food or drink.• Some chewable tablets may be crushed and mixed with food or
drink.
USAID APHIA IINAIROBI/CENTRAL
Types of Antiretroviral Drugs
1. Nucleoside reverse transcriptase inhibitors (NRTI)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTI)
3. Protease inhibitors (PI)
USAID APHIA IINAIROBI/CENTRAL
Antiretroviral Agents
• NRTI Nucleoside Reverse Transcriptase Inhibitor
– Zidovudine (AZT,ZDV)– Didanosine (ddI)– Zalcitabine (ddC)– Stavudine (D4t)– Lamivudine (3TC)– Abacavir (ABC)– Emtricitabine (FTC)
• Nucleotide analogues– Tenofovir (Viread)
• NNRTI Non-Nucleoside Reverse Transcriptase Inhibitor
– Nevirapine (NVP)– Delavirdine (DLV)– Efavirenz (EFV)
USAID APHIA IINAIROBI/CENTRAL
Antiretroviral Agents
• PI- Protease Inhibitors
– Saquinavir (SQV)– Ritonavir (RIT)– Indinavir (IDV)– Nelfinavir (NFV)– Amprenavir (APV)– Lopinavir/ritonavir (LPV/r)– Atazanavir (ATZ)
• Fusion inhibitors– Enfuvirtide (T-20)
Entry inhibitors-Maraviroc
USAID APHIA IINAIROBI/CENTRAL
Kenya national recommended 1st line ART in children
Always give three drugs (triple therapy). National first line regimen – use 2 NRTIs and 1 NNRTI
Age < 3 years• Zidovudine (ZDV) + Lamivudine (3TC) + Nevirapine (NVP)
Age > 3 years• ZDV + 3TC + Efavirenz (EFV) or NVP.
These can be taken with or without food, taste is acceptable, and all are stable at room temperature.
If child very anaemic, ZDV may be substituted by stavudine (D4T)
USAID APHIA IINAIROBI/CENTRAL
First line regimen in NVP-exposed child
Child exposed to single dose Nevirapine for PMTCT may have NVP resistant virus. Avoid NNRTI in their 1st line regimen
• AZT (or d4T) + 3TC +LPV/r (Kaletra)
USAID APHIA IINAIROBI/CENTRAL
ART and Tuberculosis
Rifampicin interacts with Nevirapine and most protease inhibitorsIf possible, complete anti-TB therapy before ART initiation. If child too sick to wait, and anti-TB therapy must be given with ART
use the following regimen:• Child < 3 yr – Replace NVP with Abacavir. After completing anti-
TB therapy revert to NVP• Child > 3 yr – Two NRTIs with Efavirenz
USAID APHIA IINAIROBI/CENTRAL
Dosages of ARV drugs
• Many are calculated using surface area• S.A = sq root of ([wt x ht] / 3600)• Others calculated using weight for age- charts• Failure to compute dosage correctly leads to
under- or over-dosing• Suboptimal dose – resistance• Overdose – toxicity
USAID APHIA IINAIROBI/CENTRAL
Drug Formulation Dose Adverse effects
Comments
Stavudine Syrup 1mg/ml, 200ml;Caps 15, 20,30mgFDCs
1mg/kg/dose BDMax: 30 mg
Peripheral neuropathy; lipodystrophy
•Reconstituted syrup needs refrigeration </= 1mth;•Not to be used with AZT•No food restrictions•Dose adjustment in Renal Failure
Lamivudine Oral solution 10mg/ml, 100mls, 240mls;Tablets 150mgFDCs
4mg/kg/dose BD, >12yrs or 60kg+ 150mg BD
Well toleratedMay be associated with hepatitis
•Store solution at 25-25 0C for </= 1mth•No food restrictions•Dose adjustment in Renal Failure
Zidovudine Syrup 10mg/ml, 240ml; Caps/Tab 100mg, 300mg;Inj. IV 10mg/ml, 5ml; FDCs
240mg/m2/dose BD; >12yrs, 300mg BDHIV encephalopathy: 300mg/m2/dose BD
•Bone marrow suppression (anemia and/or neutropenia)
No food restrictionsSyrup stable at 15-25o x 1mthNot to be used with d4TDose adjustment in
Renal/Hepatic Failure
NRTIs I
USAID APHIA IINAIROBI/CENTRAL
Drug Formulation Dose Adverse effects
Comments
Abacavir Oral solution 20mg/ml,
240ml; Tablets 300mg 8mg/kg/dose BD, max 300mg BD. Over 37.5kg or over 16 years: 300mg BD
Hypersensitivity reactions (i.e. rash, fever, GI and RT symptoms)
1.Not to be used in children< 3mths2.No food restrictions3.Educate patient/carer re: hypersensitivity reaction3. DO NOT re-challenge after reaction
Tenofovir Tabs 300mgFDC with Emtricitabine
300 mg OD Well tolerated Renal impairment reported
Not recommended in combination with ddI, if used, close monitoring needed
Take with meal
Didanosine Dispersible buffered tablets25/100/200mg/400mg Chewable/dissolved in water/apple juice
100-120 mg/m2/dose BD
•Pancreatitis •Peripheral neuropathy•GI intolerance
Take on empty stomach (>1/2 hour pre or> 2hour post meal)
NRTIs II
USAID APHIA IINAIROBI/CENTRAL
Drug Formulation Dose Adverse effects
Comments
Nevirapine Oral Suspension 10mg/ml, 100mls, 240mlTablets 200mg
4mg/kg OD for 14 days, then 7mg/kg BD for <8yrs. For >8 years 4mg/kg BD max 200mg
•RASH•Hepatoxicity
Store suspension at room temperature.Need to monitor LFTs in first few monthsEducate patient/carer about rash.
Auto induced metabolism in the first 2-4 weeks with a 2 fold increase in clearance hence higher dosing after 2 weeks.
Efavirenz Capsules 50mg/200mg/600mgSyrup 30mg/ml., 180ml
10-14kg: 200mg, 15-19kg: 250mg, 20-24kg: 300mg; 25-32.5kg: 350mg 33-39kg:400mg> 40kg: 600mg
•CNS disturbances•Teratogenic (DO NOT use in pregnancy)•Hepatitis
•Avoid high fat meal as increases absorption, drug levels and side effects
NNRTIs
USAID APHIA IINAIROBI/CENTRAL
Drug Formulation Dose Adverse effects Comments
Ritonavir 100 mg capsuleSyrup 80mg/ml
Now used predominantly as a mini-dose for purposes of “boosting” other PIs
•GI Intolerance•Taste perversion.•transaminases, CPK uric acid•Class side effects
Used as PI booster.Refrigeration required if solution or
caps kept for > 30 days Oral solution contains alcohol 12%.
Lopinavir/ritonavir (KaletraTM)
Capsules 133.3mg/33.3mg Oral solution 80mg/20mg per ml
7-15kg-0.15ml/kg BD15-40kg-0.125ml/kg BD> 40kg: 3 capsules BD (400/100)
•GI Intolerance•Taste perversion•Hepatitis •Class side effects
Refrigerate reconstituted solution. Stable for 30 days.
Give with food. Moderate fat meal increases bioavailability.
Storage at <25OC for up to 2 months
Nelfinavir 250 mg capsules50mg/g oral powder
55-75mg/kg/dose BD, max 1250mg BDOr 750mg TDS
•Diarrhea •Class side effects
Food increases levels by 2-3X. Take with meals, preferably high fat meal
Indinavir 200, 333, 400mg capsules
800 mg TDSOR800mg with RTV BD
•Kidney stones (take >2litres fluid/day)•Inc indirect bilirubin •Class side effects
Separate from buffered ddI by 2hoursTake on empty stomach (1 hr pre or 2hr
post meals)No food effect when taken with RTV
PIs
USAID APHIA IINAIROBI/CENTRAL
Clinical Monitoring
• Clinical response – anthropometry, physical exam at every visit– Symptoms improving, static, deteriorating?– Growth (weight, height)– General well-being
• Clinical signs of specific adverse effects (depend on class of drugs)
USAID APHIA IINAIROBI/CENTRAL
Laboratory Monitoring
• Response to therapy– CD4 every 6 months (expect rise within 6 months)– Viral load at baseline, month 3 then every 6 months if
affordable (aim at 5-fold drop by 8-12 weeks)• Adverse effects
– FBC, SGPT/ALT at baseline, month 1, then 3 monthly or as appropriate
– Others (lipids, glucose etc) as appropriate for toxicity or inter-current illnesses
USAID APHIA IINAIROBI/CENTRAL
When to change or stop ART
1. Toxicity – replace only the offending drug
2. Treatment failure – replace all 3 drugs
3. Poor adherence – if cannot rectify, withdraw ART
USAID APHIA IINAIROBI/CENTRAL
When to change ART
Toxicity – replace offending agent only with equivalent drug
• Hb < 7gm/dl• Platelets < 49,000• Neutrophils < 250• Bilirubin 3-7x upper normal• SGPT 10x upper normal• Amylase, lipase: 2-3x upper normal• Neuropathy, severe dermatitis • Lipoatrophy, pancreatitis
USAID APHIA IINAIROBI/CENTRAL
Indications for change of therapy – treatment failure
FIRST CHECK ADHERENCE!!
Clinical indications• Progressive neurodevelopmental deterioration• Growth failure • Disease progression – move from one stage to
next
USAID APHIA IINAIROBI/CENTRAL
Indications for change of therapy – treatment failure
Immunological indications• For kids with CD4 below 15%, decline of ≥ 5
percentile points• Rapid decline in absolute CD4 count (loss of >
1/3 of CD4 cells in < 6 months)
USAID APHIA IINAIROBI/CENTRAL
Indications for change of therapy – treatment failure
Virological indications
• Persistent increase in viral load (confirmed by 2 tests)
USAID APHIA IINAIROBI/CENTRAL
Second line therapy – factors to consider
• Change ALL 3 DRUGS.• Include a Protease inhibitor.• Replace the NRTIs with two new NRTIs• Replace the NNRTI with a PI• IF initial problem was adherence to therapy, must address
this first. If can’t, best to just withdraw therapy altogether
USAID APHIA IINAIROBI/CENTRAL
Kenya national recommended 2nd line ART in children
First line• ZDV/3TC/NVP or EFV
• d4T/3TC/NVP or EFV
• ZDV/3TC/Kaletra
Second line• ddI/ABC/LPV/r or ddI
/ABC/NFV
• ddI/ABC/LPV/r or NFV• ddI /ABC/PI/ ritonavir
USAID APHIA IINAIROBI/CENTRAL
When To Stop/withdraw ART.
ART should be withdrawn in the following situations:
• Severe adverse effects (lactic acidosis)• Intolerability, inability to take drugs.• Poor adherence• Interruption of drug supply • Patients wish.
USAID APHIA IINAIROBI/CENTRAL
Immune Reconstitution Inflammatory Syndrome (IRIS)
• Inflammatory disorders associated with paradoxical worsening /atypical presentation of preexisting infectious processes following the initiation of highly active antiretroviral therapy
• Preexisting infections in individuals with IRIS mat have been previously diagnosed and treated or they may be subclinical and alter unmasked by thr host’s regained capacity to mount inflammatory response
USAID APHIA IINAIROBI/CENTRAL
IRIS-cont..
• Systemic or local inflammatory reactions may occur at the site or sites of the pre-existing infection.
• Reaction is usually self-limited, especially if the pre-existing infection is effectively treated.
• Long-term sequelaeand fatal outcomes may rarely occur when neurologic structures are involved.
USAID APHIA IINAIROBI/CENTRAL
IRIS
• IRIS appears to be most prevalent in people with• A severely compromised immune system at baseline, • Start of ART soon after of Rx of O.I.• Genetic mutationsof their innate cytokines eg TNF Management:• Antimicrobial agents directed at the underlying infection/
intesification of medications.• Steriods or nonsteroidal anti-inflammatory agents.• Continued use of HAART may be all that is necessary for IRIS to
resolve.
USAID APHIA IINAIROBI/CENTRAL
Module 7
Case StudiesPatient MO
USAID APHIA IINAIROBI/CENTRAL
MO
• 6 months old• History
– Persistent diarrhoea– Recurrent mouth sores– Weight loss– Mother had TB 1 year ago– Two previous hospitalizations with pneumoniaQ 1 Do you suspect HIV? If so, why?
USAID APHIA IINAIROBI/CENTRAL
MO
• Exam– Weight 3.5kg, height 60cm, wasted, dehydrated, severe
oro-pharyngeal thrush, has not achieved head support.
Q 2 What is his clinical stage? (WHO and CDC)
Q 3 How would you confirm his HIV status?
USAID APHIA IINAIROBI/CENTRAL
MO
See his lab tests (MO 1 to MO 3)
Q4 Compute his TLC from the first FBC report (June 2003)
Q 5 Based on his TLC is he immuno-suppressed?
Q 6 Compute his TLC and CD4 % from his CD4 report (July 2003)
Q 7 What is his immunological category?
USAID APHIA IINAIROBI/CENTRAL
MO
Q8 Does MO require antiretroviral therapy?
Q9 If yes, which ARV drugs would you prescribe?
Q10 What is his surface area?
Q11 What doses and formulations would you administer?
USAID APHIA IINAIROBI/CENTRAL
MO
• M.O. started on antiretroviral therapy
Q 12 Compute his TLC and CD4% in January 2005 after 15 months of ART
USAID APHIA IINAIROBI/CENTRAL
Adherence Issues to Consider
• Children depend upon adults to administer drugs• Adherence may be affected by stage of development
(spitting, vomiting, running away)• Providers need to teach families techniques of giving
medicine to young children– Use of syringe for measurement and administration– Crushing of meds– Mixing in fruit juice, other foods– Opening of capsules– Repeat dose if vomited
USAID APHIA IINAIROBI/CENTRAL
Case Studies Module 7
HIV-Related DiseasesCase - Katindi
USAID APHIA IINAIROBI/CENTRAL
Katindi – 6 years
Full blown AIDSWeight 14kg, height 90cmStarted on co-trimoxazole 5 ml once daily
Q1 Is the dose appropriate?
USAID APHIA IINAIROBI/CENTRAL
Katindi
• Katindi developed severe Steven Johnsons reaction to the cotrimoxazol
Q 2 How will you manage her?Q3 After stabilised, how is it possible to
continue to give her prophylaxis against PCP? How
USAID APHIA IINAIROBI/CENTRAL
Katindi
While you are deciding what to do about her prophylaxis, she presents in casualty with
• Severe cough of 1 weeks duration• Afebrile, Cyanosis• RR 90/min• Clear chest
Q4 What is the diagnosis?Q5 How will you treat her?
USAID APHIA IINAIROBI/CENTRAL
CASE PRESENTATION: SK
USAID APHIA IINAIROBI/CENTRAL
CASE SMK BORN JUNE 2002.
• Birth weight 2.6kg. • Apgar score 9/1, 10/5• Second born.• Older sibling male, born in 1999 Nov.
USAID APHIA IINAIROBI/CENTRAL
Progress:
•6weeks: 4.2kg. Thrush noted. On breast-milk and formula.
•12weeks: 5.3kg. Not breastfeeding.Mother on undisclosed drugs.
Unwilling to discus her own condition.
USAID APHIA IINAIROBI/CENTRAL
• How would you counsel the mother?• What would you like to know from her?
USAID APHIA IINAIROBI/CENTRAL
• 18weeks: 6.4kg. Noted to have generalized lymphadenopathy,
• and hepato-splenomegally.• Would you suspect HIV?• How would you proceed?
USAID APHIA IINAIROBI/CENTRAL
• Mother on ddI, d4T, EFZ.• 22weeks: 7.2kg. Multiple abscesses, nappy
dermatitis, severe oral thrush, hepatosplenomegally and generalized lymphadenopathy.
• Mother agreed HIV tests for baby.What is the WHO clinical staging?Which tests would you order?
USAID APHIA IINAIROBI/CENTRAL
• If mother cannot afford PCR test, what would you do?
• When then is the earliest you can confirm the child’s diagnosis?
USAID APHIA IINAIROBI/CENTRAL
• HIV diagnostic test: Viral load by Amplicor HIV-1 monitor version1.5:
• 9,818copies/ml.• WBC 21 300, Lymphocytes 72% (15 336)• Hb. 11.2g/dl, platelets 343.• Comment on these results.• Do they change the child’s clinical stage?
USAID APHIA IINAIROBI/CENTRAL
• Mother came for results one month latter.• Child now 7months old. In addition to above symptoms
noted to have parotid enlargement, palpable lymph node in the left cubital area.
• Temp. 38.2C, respiratory rate 74/min. with chest retractions, cyanosed, normal breath sounds.
USAID APHIA IINAIROBI/CENTRAL
• What are the possible diagnoses?• What is the child’s clinical stage now?• How would you manage his acute problem?
USAID APHIA IINAIROBI/CENTRAL
• Treated with cotrimoxazole and cefprozil.• ARVs to be started when parents ready.
USAID APHIA IINAIROBI/CENTRAL
• 8months:8.7kg. Admitted with severe pneumonia. Chest x-ray: bi-basal and perihilar nodular opacities. WBC 16 400, Lymph. 67%. Hb. 10.1g/dl
• CD4 1,889 or 17%.• Viral load 380 000copies/ml.• What is his immunological stage?• Discuss management.
USAID APHIA IINAIROBI/CENTRAL
• Started on AZT, 3TC, NVP. co-trimoxazole prophylaxis.
• One month latter, aged 9months: Admitted with fever for one day and refusal to feed.
• Cough had continued since the last admission one month ago.
• Chest x-ray: pneumonia.
USAID APHIA IINAIROBI/CENTRAL
• Mantoux test ulcerative• Sputums positive for AAFBS. (three slides)• What do you think is happening? • Discuss management of the patient and the
family. (Mother on ART, father positive but healthy, older sibling’s status not known.)
USAID APHIA IINAIROBI/CENTRAL
• Treated with INH, PZA, RFP for 2months. Then INH, RFP for 4months.
• ART changed to AZT, 3TC, ABC.
USAID APHIA IINAIROBI/CENTRAL
• 20th. September 2003, age 1year 3months: 11kg. No lymphadenopathy, liver and spleen not palpable. Parotids not enlarged.
• TB treatment over
• What should be done next?
USAID APHIA IINAIROBI/CENTRAL
• May 2004: 13kg. Viral load <50copies/ml• CD4 2,330 (16%)• Abacavir not available.
• What are your options?
USAID APHIA IINAIROBI/CENTRAL
• Was changed to NVP, AZT, 3TC.• July 2005: 18kg.Viral load <50copies/ml• CD4 20%
• Your comments?• Discuss future plans.
Recommended