Package Of Care for Children and Adolescents with Advanced HIV … · 2021. 1. 13. · Optimize Early ART initiation within 7 days, optimal regimen (LPV/R or DTG), S counselling Addressing

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

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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!









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

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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








• 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

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• 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


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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

20, Avenue Appia1211 Geneva

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/

http://www.who.int/

http://www.gap-f.org/

http://www.who.int/hiv/pub/paediatric/aids-free-toolkit/en/

http://www.who.int/hiv/pub/research-dev-toolkit-paediatric-arv-drug-formulation/en/

Documents

Package Of Care for Children and Adolescents with Advanced HIV … · 2021. 1. 13. · Optimize Early ART initiation within 7 days, optimal regimen (LPV/R or DTG), S counselling Addressing