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Package Of Care for Children and Adolescents with Advanced HIV Disease: STOP AIDS
Dr. Martina Penazzato
CDC/CHAI/UnitaidTeleECHO™ Sessions
Package of Care for children and adolescents with Advanced HIV disease: STOP AIDS
Dr. Martina Penazzato
Paediatric HIV lead
Global HIV, Hepatitis and STIs programme
WHO HQ Geneva Switzerland
January 13, 2021
53% of children living with HIV are receiving treatment compared to 68% of adults
• Only 950,000 children receiving treatment in 2019
• Children living with HIV is declining as children age into adulthood
• Most recent data suggest lower numbers in mid-2020
1,400,000
- 500,000
1,000,000 1,500,000 2,000,000 2,500,000 3,000,000
Number of children living with HIV and receiving ART, globally , 2010-2019
Receiving ART CLHIVSource: UNAIDS 2020 Estimates
30% of children and adolescents still present with severe immunosuppression
Tuberculosis, severe bacterial infectionsremain leading causes of mortality
Ford et al, Lancet HIV 2016
WHO guidelines for Managing Advanced HIV Disease and Rapid Initiation of ART
Evidence that packaged Interventions for advanced disease reduces mortality: REMSTART and REALITY
Advanced HIV disease is defined as CD4 count <200 cells/mm3 or WHO clinical stage 3 or 4
(All children <5 years old considered to have advanced disease)
2017 WHO recommendations for AHD
A package of interventions including :
• screening, treatment and/or prophylaxis for major opportunistic infections,
• rapid ART initiation, and
• intensified adherence support
should be offered to everyone presenting with advanced HIV disease
(strong recommendation, moderate-quality evidence).
2020 AIDS FREE TOOLKIT UPDATESSupporting countries to advance care for children and adolescent living with HIV
Definition of advanced disease in children: further articulated in 2020 technical brief
Children > 5 years:
WHO stage 3 or 4 or a CD4 cell count <200 cells/mm3
Children < 5 years:
Considered to have advanced HIV disease
“Although children younger than five years are defined as having advanced disease at presentation, those who have been receiving ART > 1 year and who are clinically stable should not be considered to have advanced disease and should be eligible for multi-month dispensing”
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counsellingS
T
O
P
Addressing advanced HIV disease: The difficult part we always forget
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counsellingS
Addressing advanced HIV disease: The difficult part we always forget
30% of children and adolescents still present with severe immunosuppression
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
Key components to Screen
Molecular TB testing
• Collecting sputum samples can be difficult for children
• Gastric specimens, nasopharyngeal specimens and stool specimens can be considered
Across 140 high-burden developing countries (Cepheid’s HBDC program), over 11,694 devices have been delivered, comprising 52,058 modules.
LF-LAM for screening active TB
Screen Key Messages
• Critical and supportive diagnostics exist to support children with advanced HIV disease
• LF-LAM (using urine) is a key diagnostic to identify TB in children
• Molecular TB testing can now use non-sputum specimens for diagnosis
• Rapid and simple cryptococcal antigen testing is now available for diagnosis in adolescents
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counselling
T
Addressing advanced HIV disease: The difficult part we always forget
30% of children and adolescents still present with severe immunosuppression
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
Treatment of cryptococcal disease in children:
• First week:
• Amphotericin B deoxycolate
• Flucytosine
• Second week:
• Fluconazole
Treat: Key messages
• Treatment of TB requires ARVs dose adjustment
• Treatment of severe bacterial infections (Streptococcus, Staphylococcus, Salmonella) and severe pneumonia (including PCP for infants)
should follow WHO guidelines
• Malnutrition, main driver of mortality
Treatment of malnutrition in children living with HIV
• Should start ART as soon as possible after stabilization of metabolic complications and sepsis
• Should be managed with the same therapeutic feeding approach as HIV negative
• Should receive high dose vitamin A and zinc (included in F-75, F-100 and RUTF)
WHO: Management of severe malnutrition
Treatment of TB in children living with HIV
TB Treatment is standard but dose adjustment of ARVs is required
• LPV/r: Super-boosting with additional RTV
• DTG: same dose but twice a day
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counsellingO
Addressing advanced HIV disease: The difficult part we always forget
30% of children and adolescents still present with severe immunosuppression
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
• Enable rapid ART initiation
• Co-morbidities might required stabilization before ART is started
• ART initiation to happen during admission to reduce LTFU
• Ensure linkage to the facility providing routine care after discharge
• Counselling and support
Optimize: Key messages
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counselling
P
Addressing advanced HIV disease: The difficult part we always forget
30% of children and adolescents still present with severe immunosuppression
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
• Vaccinations: catch up pneumococcal vaccine but also remember BCG, measles, HPV
• CTX for CLHIV remains a core intervention despite scale up of ART
• 6 months INH remains an effective approach suitable to all children living with HIV, 1HP and 3HP require more data on drug drug interaction with LPVr and DTG to be fully implemented for CLHIV
• Fluconazole for adolescents with CrAg positive
Prevent: Key messages
OptimizeEarly ART initiation within 7 days, optimal regimen (LPV/R or DTG), counsellingS
T
O
P
Addressing advanced HIV disease: The difficult part we always forget
30% of children and adolescents still present with severe immunosuppression
Sources: WHO (2020), Package of CARE for Children and Adolescents with Advanced HIV Disease (AHD): “STOP-AIDS”
PreventTB, PJP, cryptococcus, pneumonia and catch-up immunizations
ScreenFor TB, cryptococcal disease, developmental delay
TreatFor TB, cryptococcal disease, severe pneumonia
We need to Stop AIDS!
Implementation Considerations (1)
National• As the AHD package is implemented it’s critical
harmonize and align various recommendations adopted by the country
• Registration and procurement of commodities essential step for implementation
• Policies and protocols to enable catch up vaccinations outside of EPI
Facility• Hub-and-spoke model central to current
implementation • Important to enable and support task-shifting for some
components of the package• Ensuring right mix of commodities, screening tools and
child-friendly environment at the facility level • Protocols for referral
Implementation Considerations (2)
Health care providers• Training, capacity building and supported supervision
(inclusion of AHD package in training curriculum)• Limited access to specific diagnostic tools should not
prevent clinical diagnosis and treatment
Laboratory • Ensuring SOPs are in place as well as training, capacity
building activities (ie sample collection for TB screening)
• Explore capacity for AMR surveillance
Monitoring• Drug toxicity • Ensuring development of tools to tack implementation
of the package
Research gaps
Useful resources (1)• Rapid communication: molecular assays as initial tests for the diagnosis of tuberculosis and rifampicin resistance. Geneva: World Health
Organization; 2020 (https://www.who.int/tb/publications/2020/rapidcommunications-molecular-assays/en).
• Guidelines for the diagnosis, prevention, and management of cryptococcal disease in HIV-infected adults, adolescents and children. Supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2018 (https://www.who.int/hiv/pub/guidelines/ cryptococcal-disease/en).
• WHO, UNICEF. Statement on the use of child-friendly fixed-dose combinations for the treatment of TB in children. Geneva: World Health Organization; 2017 (https://www.who.int/tb/publications/ ChildTbStatementfixed-dose combinations/en)
• Pneumonia and bloodstream infections: Integrated management of childhood illness for high HIV settings. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/44010).
• Guidelines for the diagnosis, prevention, and management of cryptococcal disease in HIV-infected adults, adolescents and children. Supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2018 (https://www.who.int/hiv/pub/guidelines/ cryptococcal-disease/en).
• Nutrition for HIV-infected infants and children (Chapter 14). In: Antiretroviral therapy of HIV infection in infants and children: towards universal access: recommendations for a public health approach – 2010 revision. Geneva: World Health Organization; 2010 (https://apps.who.int/iris/bitstream/ handle/10665/164255/9789241599801_eng.pdf; jsessionid=26591810CC4A1EB29C4F4B9BD9 B9522F?sequence=1).
• Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2020 (https://www.who. int/publications-detail-redirect/9789241506328).
• Update of recommendations on first- and second-line antiretroviral regimens: policy brief. Geneva: World Health Organization; 2019 (https://www.who.int/hiv/ pub/arv/arv-update-2019-policy/en).
• Pediatric ARV counseling cards and job aids [website with toolkits]. New York: ICAP at Columbia University Mailman School of Public Health; 2020 (https:// icap.columbia.edu/tools_resources/pediatric-arvcounseling-cards-and-job-aids).
• WHO operational handbook on tuberculosis: module 1: prevention: tuberculosis preventive treatment. Geneva: World Health Organization; 2020 (https:// www.who.int/publications/i/item/who-operationalhandbook-on-tuberculosis-module-1-preventiontuberculosis-preventive-treatment).
Useful resources (2)• WHO consolidated guidelines on tuberculosis: module 1: prevention: tuberculosis preventive treatment. Geneva: World
Health Organization; 2020 (https:// www.who.int/publications/i/item/who-consolidatedguidelines-on-tuberculosis-module-1-preventiontuberculosis-preventive-treatment).
• Prevent TB digital platform [website]. Geneva: World Health Organization; 2020 (https://www.who.int/ activities/preventing-tb#app).
• Catalyzing Pediatric Tuberculosis Innovations (CaP TB): short-course treatment regimens to prevent TB: 3HP and 3RH. Paris: Unitaid; 2020 (https://unitaid.org/ assets/Catalyzing-Pediatric-Tuberculosis-InnovationsCaP-TB.pdf).
• BCG vaccines: WHO position paper – February 2018. Geneva: World Health Organization; 2018 (https:// www.who.int/immunization/policy/position_papers/ bcg/en).
• Summary of the WHO position on measles vaccine – April 2017. Geneva: World Health Organization; 2017 (https://www.who.int/immunization/policy/position_ papers/WHO_PP_measles_vaccine_summary_2017. pdf?ua=1).
• Summary of the WHO position paper on vaccines against human papillomavirus (HPV), May 2017. Geneva: World Health Organization; 2017 (https:// www.who.int/immunization/policy/position_papers/ pp_hpv_may2017_summary.pdf?ua=1).
• Summary of WHO position paper on pneumococcal conjugate vaccines in infants and children under 5 years of age, February 2019. Geneva: World Health Organization; 2019 (https://www.who.int/ immunization/policy/position_papers/who_pp_ pcv_2019_summary.pdf?ua=1).
• Plan an order [website]. Geneva: Stop TB Partnership; 2020 (http://www.stoptb.org/gdf/planOrder.asp).
• GDF product catalog [website]. Geneva: Stop TB Partnership; 2020 (http://www.stoptb.org/gdf/drugsupply/product_ catalog.asp).
• Rifapentine global price discount. Paris: Unitaid; 2020 (https://www.impaact4tb.org/wp-content/uploads/2019/11/ Rifapentine_Global_Price_Discount_Communique.pdf).
• Global advanced HIV disease toolkit [website]. London: International AIDS Society; 2020 (http://www.differentiatedcare. org/Resources/Resource-Library/Global-Advanced-HIV-DiseaseToolkit).
Thank you
WHO
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Switzerland
www.who.int
www.gap-f.org/
www.who.int/hiv/pub/paediatric/aids-free-toolkit/en/
www.who.int/hiv/pub/research-dev-toolkit-paediatric-arv-drug-formulation/en/