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Pediatric HIV/AIDS

Pediatric HIV/AIDS. Courtesy of: International Center for AIDS Care and Treatment Programs Columbia University Mailman School of Public Health. Overview. Learning Objectives: Overview and Challenges. Describe the scope of the pediatric HIV/AIDS epidemic in Sub-Saharan Africa and Ethiopia

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Pediatric HIV/AIDS

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  1. Pediatric HIV/AIDS Courtesy of: International Center for AIDS Care and Treatment Programs Columbia University Mailman School of Public Health

  2. 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

  5. Eastern Europe & Central Asia 8 800 [7 100 – 13 000] Western & Central Europe 6 200 [4 900 – 7 900] North America 11 000 [5 600 – 17 300] East Asia 9 400 [3 300 – 27 000] North Africa & Middle East 24 000 [7 100 – 82 000] Caribbean 23 000 [12 000 – 49 000] South & South-East Asia 170 000 [95 000 – 320 000] Sub-Saharan Africa 1.9 million [1.7 – 2.3 million] Latin America 26 000 [21 000 – 43 000] Oceania 700 [< 2 500] 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]

  6. Western & Central Europe < 100 Eastern Europe & Central Asia 1 800 [1 200 – 3 700] North America < 100 East Asia 4 100 [1 500 – 11 000] North Africa & Middle East 9 100 [2 800 – 30 000] Caribbean 6 100 [3 100 – 13 000] South & South-East Asia 51 000 [30 000 – 95 000] Sub-Saharan Africa 560 000 [500 000 – 650 000] Latin America 6 800 [5 400 – 11 000] Oceania < 300 [< 1 000] Estimated Number of Children (<15 years) Newly Infected with HIV During 2005

  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 administration • Procurement of pediatric formulations • Weight-based dosing • Pediatric adherence • Infrastructure & human resource requirements • PMTCT follow up • Systems 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 services • Widespread use of OI prophylaxis (cotrimoxazole) • Access to antiretroviral therapy • Successful 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 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. Pediatric Care and Treatment (2) • 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

  15. 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 infants • for rapid disease progression and failing health status • Use of prophylaxis in HIV-exposed infants • to 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 failure • Tuberculosis • PCP • HIV encephalopathy • Bacterial 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

  26. WHO Growth Curves • WHO growth curves are • Age and gender specific • Extend 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

  27. WHO Child Growth Curves

  28. CDC Growth Curves • CDC growth curves are • Age and gender specific • Extend 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 years • Head circumference for boys and girls < 3 years

  29. How to Use and Interpret a Growth Curve • Measure and weigh child using same methodology at each visit • Use 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

  30. Weight for Age The child is in the 15th percentile of weight for age The child weighs 6kg He is4 months old

  31. Head circumference for age Age is 3 months 95 90 75 50 25 10 5 Head circumference is 38 cm The head circumference is below the 5th percentile for age This child is microcephalic

  32. Clinical Care: Growth and Nutrition • Nutrition: • Assess mode of feeding • frequency (duration or ounces) • adequacy of supply • bowel habits, reported problems • Infant feeding practices

  33. 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. 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 Breast Feeding

  35. 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 Formula Feeding

  36. Summary: Infant Feeding • Choosing to breast feed or formula feed is complex: • Personal preference of woman/family • Local community norms • Availability 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 child • Assure accurate history of intake • Assess 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

  38. Clinical Care: Developmental Assessment (2) • A developmental assessment that includes the following should be conducted at each visit: • Cognitive, motor, language, and social skills • Discuss the infant’s milestones • Verify appropriate development for age • Use a developmental check list or observe the infant during the examination

  39. 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, laughs • 6 months: sits unsupported, babbles • 9 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

  41. Clinical Care: Cotrimoxazole Preventive Therapy (2) • 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

  42. Diagnosis of PCP in HIV-Infected Children with Respiratory Disease % PCP

  43. 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. CPT Dosing Recommendations *or one double strength tab

  45. 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 required • Systematic follow up is vital • Appointment systems • Medical records • Family education and support

  48. Visit Schedule Follow-up Schedule for theHIV-exposed Infant Monthly visits for the first 6 months, then every three months until HIV infection status determined 4-6 weeks 3 months 5 months 9 months 15 months 6 months 2 months 4 months 12 months 18 months Virologic test HIV antibody testing 12 months Follow-up schedule can be modified per local and national guidelines.

  49. 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?

  50. 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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