Hiv aids and the pediatric patient
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HIV/AIDS and the Pediatric Patient. Prepared by Kate Powis, MD Global Women’s Health Fellow Harvard Medical School Instructor. Presentation Objectives. HIV Epidemiology Pathophysiology Presentation in the Pediatric Population Testing Clinical Staging Treatment Ongoing Care Issues.

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Hiv aids and the pediatric patient

HIV/AIDS and the Pediatric Patient

Prepared by Kate Powis, MD

Global Women’s Health Fellow

Harvard Medical School Instructor


Presentation objectives

Presentation Objectives

  • HIV Epidemiology

  • Pathophysiology

  • Presentation in the Pediatric Population

  • Testing

  • Clinical Staging

  • Treatment

  • Ongoing Care Issues


Hiv aids and the pediatric patient

Estimated number of people living with HIV globally,

1990–2007

40

Millions

30

Number

of people

living

with HIV

20

10

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Year

This bar indicates the range

1

2007 AIDS Epidemic Update


Hiv aids and the pediatric patient

Estimated number of adult and child deaths

due to AIDS globally, 1990–2007

3.0

Millions

2.5

2.0

Number

of adult

and child

deaths due

to AIDS

1.5

1.0

0.5

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Year

This bar indicates the range

3


Hiv aids global statistics

HIV/AIDS Global Statistics

  • 33.2 million people living with HIV/AIDS worldwide as of 20071

  • 90% of HIV/AIDS infected persons live in developing countries1

  • 2.1 million children under age 15 were living with HIV/AIDS in 20072

  • Globally, 1,150 of newborns are infected daily by peri-natal transmission of HIV2

  • In 2007, 420,000 children were newly infected with HIV and 290,000 died of AIDS2

1UNAIDS 2007 World Report

2http://www.uniteforchildren.org/knowmore/knowmore_30104.htm


Hiv aids global statistics1

HIV/AIDS Global Statistics

  • In 2007, the number of new HIV infections was 2.5 higher than the increase in the number of people receiving ARV’s1

  • Young people aged 15-24 accounted for 40% of new HIV infections among adults aged 15 years and up in 20072

  • 5.4 million young people aged 15-24 were living with HIV/AIDS in 20072

  • 50% of infected infants will die before their second birthday2

1Report of the Secretary-General; Declaration of Commitment to HIV/AIDS and Political Declaration on HIV/AIDS: midway to the Millennium Development Goals; Sixty-second session, 1-Apr-08.

2http://www.uniteforchildren.org/knowmore/knowmore_30104.htm


Hiv aids statistics in liberia

HIV/AIDS Statistics in Liberia

  • Adult prevalence of HIV/AIDS in Liberia estimated to be 5.2%.1

  • The prevalence rate of HIV in Greater Monrovia is estimated to be 9.5%1

  • UNICEF has not received reporting on incidence or prevalence of HIV/AIDS in the pediatric population of Liberia.2

1The Basic Package of Health and Social Welfare Services, Republic of Liberia, Ministry of Health and Social Welfare.

2http://www.unicef.org/infobycountry/liberia.html


Human immunodeficiency virus

Human Immunodeficiency Virus


Global distribution of hiv 1 by subtype clade

Global Distribution of HIV-1 by Subtype (Clade)

http://www.iavireport.org/


Hiv 1 particle

HIV-1 Particle

KITSO Aids Training Program, Botswana


Hiv lifecycle

HIV Lifecycle

Monini P et al, Antitumor effects of antiretroviral therapy, Nature Reviews Cancer, 4,861-875 Nov 2004.


Helper function of cd4 cells

Helper Function of CD4 Cells

Macrophage

T helper cell (CD4)

Cytotoxic TLymphocyte(CD8)

BLymphocyte

Infected cell

Antibody secreting (plasma) cell

Killed

KITSO AIDS Training Program, Botswana


Surrogate markers of hiv disease

Surrogate Markers of HIV Disease

  • CD4 cell counts reflect the strength of the immune system.

  • Viral load reflects the viral replication.


Natural history of hiv 1 infection

Acute Retroviral Syndrome

Clinical

Latency

AIDS

Natural History of HIV-1 Infection

Viral Load CD4 count

1-2 years

1-12weeks

6-10years


Pathogenesis of acute hiv 1 infection

Pathogenesis of Acute HIV-1 Infection

  • Initial infection of CD4 lymphocytes and macrophages

  • Dissemination of infection to lymph nodes

  • Burst of viral replication resulting in intense viremia

  • Development of humoral immunity (HIV-specific antibodies)

  • Development of cellular immunity (HIV-specific CD4 and CD8 cells)


Cd4 counts and opportunistic infections

CD4 Counts and Opportunistic Infections


Transmission of hiv

Transmission of HIV

  • Blood

  • Semen

  • Vaginal Fluid

  • Breast Milk


Unique features of hiv in the pediatric population

Unique Features of HIV in the Pediatric Population

  • Perinatal Infection

    • Maternal antibodies DNA PCR

  • Infection in a developing body

    • Immature Immune System CD4%

    • Immature Liver/Kidneys ARV Dosing

    • Growth ARV Dosing

    • Immature Physiology Formulations

  • Vulenrability of Children

    • Dependence on Others Adherence

KITSO AIDS Training Program, Botswan


Pediatric hiv infection common clinical presentations

Pediatric HIV Infection –Common Clinical Presentations

  • Infectious Diseases

    • Respiratory Illness (PCP, Tuberculosis)

    • Diarrheal Diseases

    • Oral Candidiasis

    • Herpes Zoster

  • Lymphadenopathy, Hepatomegaly, Parotitis

  • Persistent fever

  • Growth failure: Kwashiorkor, Marasmus

  • Developmental Delay or Regression

  • Malignancies: Lymphoma, Kaposi’s sarcoma


Diarrheal illness

Diarrheal Illness

  • Similar prevalence of stool pathogens between HIV infected and uninfected children.

  • Worse outcomes in HIV infected children.

KITSO AIDS Training, Botswana


Respiratory illness

Respiratory Illness

  • Death from respiratory tract infections:

    • PCP: Most common pathogen in HIV-infected children below six-months of age

    • Acute pyogenic pneumonia and tuberculosis common in HIV-infected and uninfected children.

KITSO AIDS Training, Botswana


Malnutrition

Malnutrition


Hiv testing

HIV Testing

  • Rapid Tests and ELISA for patients older than 18 months

  • DNA PCR for patients less than 18 months


Pediatric hiv staging

Pediatric HIV Staging

  • Facilitates assessment of degree of damage to the immune system

  • Dictates treatment timing and care options

  • Prognostic


Staging and treatment

Staging and Treatment


Goals of treatment

Goals of Treatment

  • Clinical: Prolong life, improve quality of life.

  • Virologic: Achieve maximal suppression of viral load

    • Viral load should drop by at least 1.0 after 3 months of treatment

    • Viral load should be less than 400 after 6 months of treatment

  • Immunologic: Reverse immune system damage.


Pediatric considerations in treatment selection

Pediatric Considerations in Treatment Selection

  • Availability of a suitable formulation

  • Simplicity of dosing schedule

  • Taste/palatability

  • Parent or caregiver HAART regimen


Treatment

Treatment

  • HIV infections requiring treatment warrant HAART.

  • WHO’s recommendation for first line regimen dictates the use of two NRTI’s and one NNRTI.


Haart mechanism of action

HAART - Mechanism of Action

KITSO AIDS Training - Botswana


Hiv aids and the pediatric patient

ARVs in the Liberian Formulary

NRTIs NNRTIsPIs

Nucleoside Reverse Non-Nucleoside Reverse Protease Inhibitors

Transcriptase Inhibitors Transcriptase Inhibitors

AZT(Zidovudine)EFV(Efavirenz)LPV/r(Kaletra)

3TC(Lamivudine)NVP(Nevirapine) NFV(Nelfinavir)

d4T(Stavudine)IDV(Indinavir)

ddI(Didanosine)

ABC(Abacavir)*RTV(Ritonavir)

(TZV)(AZT+3TC+ABC)


Who haart recommendation

WHO HAART Recommendation


Haart initiation considerations

HAART Initiation Considerations

  • Caregiver reliability and HIV insight

  • Infants under six months of age having received single dose NVP at birth.

  • Reproductive potential

  • CD4 with planned use of NVP


Haart labs baseline

HAART Labs - Baseline

  • CD4

  • Hematology

  • Chemistry

  • AST/ALT


Haart ongoing labs

HAART – Ongoing Labs

  • Viral load should be obtained every three months in the pediatric patient.

  • CD4 count/% should be performed at 3, 6 and 12 months post initiation. If >350 cells or 30% for one year, then annual testing thereafter unless new WHO clinical stage III or IV disease, virolgic failure or medication adherence issues are noted.


Haart ongoing labs1

HAART – Ongoing Labs

  • Hematology: If on AZT at 4 and 12 weeks post initiation, then annually or when clinically warranted. Otherwise annually or when clinically warranted.

  • AST/ALT: If on NVP-based HAART, 2, 4 and 12 weeks post initiation and therefter as clinically indicated.

  • Glucose/Cholesterol/Triglycerides: Annually for PI based regimens.


Haart dosing

HAART Dosing

  • Rechecking dosing at every visit and adjust for weight gain

  • Utilize WHO Pediatric Dosing Guides

  • Ensure dosing is a simple and convenient as possible


Changing haart regimens

Changing HAART Regimens

  • Treatment failure

  • Treatment toxicity

  • Drug Interactions

  • Adherence issues secondary to tolerance


Pediatric hiv routine care plan

Pediatric HIV Routine Care Plan

  • Pediatric HIV patients should be evaluated every three months, or sooner for acute illnesses or issue of adherence.

  • Disclosure with progressive education about HIV status, need for lifetime medications, and significance of adherence greatly improves compliance in the pediatric population.


Hiv nutrition

HIV - Nutrition

  • All HIV infected individuals should eat energy-rich foods and increase energy intake.

  • Varying foods is important to ensure micronutrient intake is appropriate.


Hiv and immunizations

HIV and Immunizations

  • Children with HIV or suspected HIV who are asymptomatic should received all appropriate vaccinations, including BCG and Yellow Fever.

  • Immunizations should be given as early as possible after the recommended age of the vaccine.

  • HIV infected children require and extra measles vaccine at 6 months of life, as well as the standard vaccine at 9 months of life.


Presentation objectives1

Presentation Objectives

  • HIV Epidemiology

  • Pathophysiology

  • Presentation in the Pediatric Population

  • Testing

  • Clinical Staging

  • Treatment

  • Ongoing Care Issues


Additional training modules

Additional Training Modules

  • HIV Prevention Programs

  • Case Presentations, HAART Dosing and Management

  • HIV and Opportunistic Infections


Thank you for your participation

Thank you for your participation!


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