facil. manual_paed hiv counseling curric

8/18/2019 Facil. Manual_paed Hiv Counseling Curric.

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PSYCHOSOCIAL CARE &

COUNSELING FOR HIV INFECTEDCHILDREN AND ADOLESCENTS

A Training Curriculum

March 2008

USAIDFROM THE AMERICAN PEOPLE


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Contents

FOREWORD iii

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Selection Criteria for Tr iivstnapicitr aPeenia

Adaptation of the Course iivsdeeNgniniar Tot

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Course Schedule ixetalpmeT

MODULE 1: OVERVIEW OF HIV INFECTION, CARE AND ART IN CHILDREN. 1MODULE 2: CHILD 22TNEMPOLEVED

MODULE 3: FAMILY STRU 43SCIMAN YDDNAERUTC

MODULE 4: PSYCHOSOCIAL ASPECTS OF PEDIATRIC HIV CARE 45

MODULE 5: COMMUNICATIN 56NERDLIHCHTIWG

MODULE 6: COUNSELI 18NERDLIHCGN

MODULE 7: WORKING WI 99STNECSELODAHT

MODULE 8: COUNSELING CHILDREN ON HIV AND AIDS 121

MODULE 9: DISCLOSURE OF HIV STATUS TO CHILDREN 134

MODULE 10: ADHERENCE TO 051NERDLIHCNITRA

561NERDLIHCROFERACEVITAILLAP:11ELUDOM

MODULE12: GRIEF A 771TNEMEVAEREBDN

MODULE 13: LEGAL AND 491SEUSSILACIHTE

MODULE 14: CARE FOR HEAL 602SREDIVORPERACHT


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FOREWORD

HIV/AIDS is a major cause of infant and childhood mortality and morbidity in Africa. Amongchildren of age


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ACKNOWLEDGEMENTS

The development and production of this training curriculum for Psychosocial Care andCounseling for HIV Infected Children and Adolescents has gone through a series of steps andhas involved several people of varying expertise and experience in the area of pediatric HIV

support, care and treatment counseling. The process began in March 2006 in Dar Es Salaam,Tanzania where AIDSRelief/CRS partnered with ANECCA to hold a regional trainingworkshop on pediatric HIV counseling. Various experts participated in the organization andconduct of this workshop. They include:

- Dr. Vicki Tepper - University of Maryland School of Medicine- Dr. Carmela Green-Abate - AIDSRelief/CRS- Dr. Nathan Tumwesigye - ANECCA/RCQHC- Dr. Margaret Makanyengo - Kenyatta National Hospital, Kenya.- Ms. Rose Nasaba - Nsambya Hospital, Uganda- Ms. Ruth Woodhead - Expert Child Counsellor - Ms. Zinat Fazal - PASADA, Tanzania.

Some of the materials developed for and used in this workshop were subsequently improvedon by a group of experts in the area of HIV counseling in Kenya, working under the auspicesof NASCOP-Kenya to develop a Kenya National Paediatric HIV/AIDSPsychosocial/Counselling Curriculum. We are grateful to the experts who contributed to thisprocess. They include:

- Mrs. Margaret Gitau- NASCOP-Kenya.- Dr. Margaret Makanyengo - Kenyatta National Hospital, Kenya- Dr. Josephine Omondi - Kenyatta National Hospital, Kenya

- Dr. Lisa Obimbo - University of Nairobi- Dr. Mbuthia - Kenya Paediatric Association- Mrs. Lilian Otieno - Gertrude Children’s Hospital- Miss. Rose Owaga - Kenyatta National Hospital- Mrs. Ruth Kinoru - Kenyatta National Hospital- Mrs. Catherine Wemmis - Kenyatta National Hospital- Mrs. Gloria Kimani - University of Nairobi- Mr. Allan Maleche - NASCOP- Mr. Gregg Stracks - USA- Dr. Sobbie Mulindi - University of Nairobi- Mrs. Betty Githendu - NASCOP

Subsequently, AIDSRelief/CRS and RCQHC/ANECCA worked together to improve and buildupon this previous work to develop these comprehensive materials to build expertise in thecounseling of children affected by HIV and/or AIDS. Working with a group of experts fromvarious countries in the East and Southern Africa region, the two organizations carried out acomprehensive review of various materials for training health care providers available in theregion and reached conclusion that a more user-friendly (to both trainers and trainees), easyto understand, yet comprehensive curriculum needed to be developed. This curriculum, withthe following components; curriculum description and implementation guide, a facilitator’smanual as well as training tools in form of Microsoft Power Point slides, role-plays, casestudies and video clips, has been designed with the expectation that it will fulfill thesecharacteristics. The experts who contributed to the process of designing and developing this

training package are:


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- Ms. Rose Nasaba - AIDSRelief/IHV Uganda.- Ms. Esther Kangavve - Mulago Hospital, Uganda.- Ms. Resty Ingabire - Nsambya Hospital, Uganda- Ms. Joyce Angulo - EGPAF, Uganda- Ms. Collette Cunnigham, CRS-SARO, Zambia.- Dr. Susan Strasser - AIDSRelief/CRS, Zambia.- Dr. Simon Kangether - Moi University, Kenya.- Dr. Margaret Makanyengo - Kenyatta National Hospital, Kenya.- Dr. Josephine Omondi - Kenyatta National Hospital, Kenya- Dr. Carmela Green-Abate - AIDSRelief/CRS.- Dr. Nathan Tumwesigye - RCQHC/ANECCA.

Their contribution is greatly valued.

The ANECCA Secretariat at the Regional Centre for Quality of Health Care, MakerereUniversity School of Public Health - provided organizational and technical leadership for theprocess. All the staff of the Regional Centre for Quality of Health Care selflessly providedsupport, in several different ways, towards the development and production of the curriculum.

The funding for the development and production of these materials has been obtained throughthe President’s Emergency Funding for AIDS Relief (PEPFAR) to Catholic Relief Services/ AIDSRelief under a grant from the Department of Health and Human Services, HealthResources and Services Administration Grant # U51HAO2521-01-01, a grant to the RegionalCentre for Quality of Health Care from the United State Agency for International Development

Grant # USAIDEA 623-SOAG623011 and Catholic Relief Services private resources. We arealso grateful to the Office for Regional Health and HIV/AIDS Programs - USAID / East Africa,who provided logistic and technical support to RCQHC/ANECCA to facilitate the process ofthe development and production of the curriculum.

External review of the training materials was done by a number of various experts from

EGPAF (Elizabeth Glazer Pediatric AIDS Foundation), WHO (World Health Organization),

University of Maryland School of Medicine, and CRS (Catholic Relief Services) - Baltimore.

Their contributions and suggestions are highly appreciated.


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DESCRIPTION AND SYLLABUS OF THE PSYCHOSOCIALCARE AND COUNSELING FOR HIV INFECTED CHILDREN

AND ADOLESCENTS TRAINING CURRICULUM

Introduction and purpose of the course

This curriculum describes a Psychosocial Care and Counseling for HIV InfectedChildren and Adolescents course. The goal of this competency-based training is toenable health care providers to provide safe high quality counseling and supportservices to HIV infected children/adolescents and their families. Using knowledge andskills acquired from this training, health care providers, particularly those involved indirectly providing counseling services, should be able to provide appropriateassessment and basic interventions.

The course materials may be delivered as a complete package or stand-alonemodules. Trainers need to tailor the course according to identified participants?knowledge and skills needs.

Target Group

The course is designed for health care providers involved in caring for children livingwith HIV/AIDS who provide counseling services to these children and their families. Itis preferable that health care workers who will attend this course should have alreadyattended a basic HIV counseling and care course.

Course Duration

The course is designed in a modular format which allows for very flexibleimplementation. It can be implemented over a minimum period of 10 days to cover allthe modules, but can also be offered as a longer course of up-to 3 weeks, dependingon the identified competency needs of trainees.

However, for busy working health care professionals several modules can be coveredat a time with subsequent coverage of the remaining modules as planned byorganizers. Ideally this should incorporate practicum and supportive supervision ifavailable.

Training and Learning Methods

Several methods are employed to facilitate learning during the conduct of the course.The organizers and facilitators should ensure that as many practical sessions aspossible are carried out to ensure retention and of newly acquired knowledge andconsolidation of skills. The following methods are encouraged, as indicated in thefacilitator’s manual:

- Classroom presentations and demonstrations

- Group discussions

- Individual and group exercises


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- Role plays

- Case studies

- Guided clinical simulation activities

- Brainstorming and experience sharing exercises.

- Video clips and reflection.

Training Materials

The following are the components of the training package:

Facilitator’s Instructions Manual

CD ROM; contains Microsoft Power Point Slides that provide aminimum content package for all the modules in the curriculum

Video clips; contain a series of unscripted interviews with HIV positivechildren illustrating issues that they face. These video clips are usedeither to demonstrate counseling techniques or to reinforce knowledgeand skills acquired in the various modules. The trainer should review thecontent of the video and be comfortable with each section so that he/shewill be able to respond to questions on issues raised.

Resource Handbook; contains factual information that relates to issues

of counselling children and their families. It can be a resource

Selection Criteria for Facilitators

Facilitators for this course should be mainly counselors or psychologists. Somemodules may be delivered by clinicians. It is essential that facilitators for this coursehave considerable experience in working with children with HIV and hold advancedfacilitation skills.

Selection Criteria for Trainee Participants

It is advisable that trainees should be carefully selected with consideration of theircurrent job description, desire to counsel children and families, as well as any previousexperience with children, if possible.

Adaptation of the Course to Training Needs

Participants who have had prior training in the area of HIV counseling (e.g. HIVcounseling for adults) as well as providers whose main area of work is not counseling(e.g. clinicians) may be offered the course as it is, focusing on practical sessions forthe more technically challenging issues of working with children. Those who have nothad prior training in the area of counseling and wish to work as counselors for childrenliving with HIV/AIDS, may need a longer version of the course that gives them enoughtime to internalize the various areas covered.


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Trainees should complete an end-of-course evaluation form that can be adapted tosuit individual program needs.

During the course, continuous evaluation of trainees should be conducted with the useof appropriate group and individual questions and session summaries. Assignmentsand group activities should be assessed and feedback given to the group

Knowledge gain can be evaluated by a written test (sample questions provided) givenat the beginning and at the end of the course (pre- and post-tests). The questionsshould be suitable to the group being trained and the competency needs as identifiedbefore the course is started.

Course Timetable Template:

The following is a generic course schedule that can be adapted to suit needs. Thesuggested average length of the course is 10 days. This can, however, be adjusted toless or more days depending on the training needs of the trainees, and other logisticand program issues.

Course Organization

A description of the content of all the modules of the course, is indicated below,followed by a course schedule template. The course organizer should complete a listof key support and referral organizations relevant for their country.

Module 1: OVERVIEW OF HIV INFECTION IN CHILDREN.

Unit:1 -Epidemiology and modes of transmission of HIV in children.

Unit:2 -Natural disease progressi on, diagnosis and staging of HIV in

children.

Unit:3 -Primary Care and Management of the HIV Positive Child.

Unit:4 -Basics of ART in children

Module 2: CHILD DEVELOPMENT

Unit:1 -Main Components of child development

Unit:2 -Factors contributing to abnormal development

Unit:3 -Identification of abnormal development

Module 3: FAMILY DYNAMICS

Unit:1 -Family-centered care

Unit:2 -Dysfunctional family systems

Unit:3 -Family assessment

Unit:4 -Family interventions and support

Methods of Evaluation:


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Module 4: PSYCHOSOCIAL ASPECTS OF PEDIATRIC HIV

Unit:1 -Psychosocial problems in children

Unit:2 -Psychosocial impact of HIV in children

Unit:3 -Psychosocial assessment and interventions

Module 5: COMMUNICATING WITH CHILDREN

Unit:1 -Introduction to communicating with children

Unit:2 -Principles of communicating with children

Unit:3 -Barriers to communicating with children

Unit:4 -Communicating with children: skills and tools

Unit:5 -Demonstration of communication skills with children

MODULE 6: COUNSELING CHILDREN

Unit:1 -Basic counseling in children

Unit:2 -The child counseling process

Unit:3 -Child counseling skills and techniques

Unit:4 -The effective counselor.

Unit:5 -Use of media and activities in counseling children

MODULE 7: WORKING WITH ADOLESCENTS

Unit:1 -Introduction to adolescence

Unit:2 -Adolescence and sexualityUnit:3 -Challenges around HIV/AIDS and the adolescent

Unit:4 -Communicating with and counseling adolescents

Unit:5 -Life skills

MODULE 8: COUNSELLING CHILDREN ON HIV AND AIDS

Unit:1 -Basic HIV counseling in children

Unit:2 -Counseling children for ART

Unit:3 -Explaining the importance of ART in child-friendly language.


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MODULE 9: DISCLOSURE

Unit:1 -Introduction to disclosur e of HIV status to children

Unit:2 -The process of disclosure

Unit:3 -Post disclosure support

Unit:4 -Barrier s to disclosure

MODULE 10: ADHERENCE TO ART

Unit:1 -Introduction to ART adherence in children

Unit:2 -Pediatric ART adherence: disclosure

Unit:3 -Pediatric ART: I ssues that affect adherence

Unit:4 -Assessing pediatric ART adherence

Unit:5 -Pediatric ART adherence: dealing with non-adherence

Unit:6 -Pediatric ART adherence: strategi es for giving medication to children

and adolescents

Unit:7 Adherence and adolescents

MODULE 11: PALLIATIVE CARE

Unit:1 -Palliative care in children

Unit:2 -Assessing children?s needs for palliative care

Unit:3 -Communicating with sick children

MODULE 12: GRIEF AND BEREAVEMENT

Unit:1 -Introduction to loss, grief and bereavement

Unit:2 -The grieving process

Unit:3 -Grief and loss in children

Unit:4 -The concept of grief and loss in children

Unit:5 -The counselor?s role and practi cal ways of helping the grieving child

MODULE 13: LEGAL & ETHICAL ISSUES IN PEDIATRIC HIV

Unit:1 -National and international fr ameworks which protect children

Unit:2 -Ethical and legal issues fa cing children living with HIV and AIDS

Unit:3 -Health care provider s? role and responsibilities


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MODULE 14: CARE FOR HEALTH CARE PROVIDERS

Unit:1 -Problems and challenges encountered in care provision

Unit:2 -Supervision and support

Unit:3 -Stress management


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MODULE OBJECTIVES:

At the end the module the healthcare worker will be able to:

1. Describe the epidemiology, modes of transmission of HIV in children.2. Explain the natural disease progression, diagnosis and staging of HIV in children.3. Describe basic components of HIV care in children

4. Explain the basic principles of ART in children

NOTES

This module consists of 4 units that are primarily lecture/discussion/demonstration. The

module provides the introduction and background to the whole problem of HIV and AIDS and it

is a good starting point for psychosocial care and counseling for children and adolescents.

SUGGESTED TRAINERS

Facilitating learning of the content of this module can be done by health care providers withpractical experience and knowledge in caring for children living with HIV/AIDS.

MODULE 1:

OVERVIEW OF HIV INFECTION, CARE AND

ANTIRETROVIRAL TREATMENT IN CHILDREN


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Time3½hrs

Objectives Content Teaching/learningmethods/activities

Resourcematerials

40mins

Unit 1

Describe theepidemiology andmodes oftransmission ofHIV in children

The unit

introducesepidemiologyand modes oftransmission ofHIV in children

Overview lecture, small

group discussions andbrainstorming.

Overhead

projector.Markers,flipcharts.Masking tapes,laptop and LCD

90

mins

Unit 2

Explain the naturaldiseaseprogression,diagnosis andstaging in children

The unit

introducesnatural diseaseprogression,diagnosis andstaging inchildren

Overview lecture, small

group discussions andbrainstorming.

Overhead

projectorComputer Power pointslides

45

mins

Unit 3Describe theprimary care andmanagement ofthe HIV positivechild

The unitintroducesprimary careandmanagement ofthe HIV positivechild

Brainstorming, smallgroup discussions andsummary presentation.

Laptop, LCDand flipcharts,markers,masking tape

45

mins

Unit 4Explain the basicsof ART in children

The unitintroducesbasics of ARTregimens usedin children

Brainstorming,Overview lecture andsmall groupdiscussions.

Laptop, LCDand flipcharts,markers,masking tape

Outline of Module 1: Overview of HIV infection, Care and ART in children


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Module 1: Slides and Instructions for Facilitators

Slide 1Module 1

Overview of HIV infection,

care and treatment in

children

Overview of HIV infection,

care and treatment in

children

On this topic, do the participants

have any ideas? They may talkabout HIV and adults. Facilitator

should emphasize that the focus is

HIV infection, care and antiretroviral

treatment in children.

Slide 2

Module 1 Objectives

Describe the epidemiology and modes ofDescribe the epidemiology and modes of

transmission of HIV in children.transmission of HIV in children.

Explain the natural disease progression,Explain the natural disease progression,

diagnosis and staging of HIV in children.diagnosis and staging of HIV in children.

Describe basic components of HIV care inDescribe basic components of HIV care in

childrenchildren

Explain the basic principles of ART inExplain the basic principles of ART in

childrenchildren

State the module objectives.

Explore the group?s experience withHIV care and treatment in children

Slide 3

UNIT 1

Epidemiology and Modes ofEpidemiology and Modes of

Transmission of HIV inTransmission of HIV inchildrenchildren

Unit 1 of this module focuses on the

epidemiology and modes of

transmission of HIV in children.

Slide 4 Invite the participants to share what

they know about the HIV pandemic

and then use this slide to

consolidate learning and key

issues.

33.3 million people living with HIV33.3 million people living with HIV

2.5 million children < 15 years2.5 million children < 15 years

2.5 million people newly infected in 20072.5 million people newly infected in 2007

420,000 children newly infected in 2007420,000 children newly infected in 2007

50% of HIV+ children die before 5 years of50% of HIV+ children die before 5 years of

age, if no interventions givenage, if no interventions given

The majority of HIV infected children are inThe majority of HIV infected children are in

subsub--Saharan AfricaSaharan Africa

Children and the HIV/AIDS Epidemic

(Global –

2007, UNAIDS)


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Slide 5

Some Factors Contributing To High HIVSome Factors Contributing To High HIV

Prevalence In Children In SubPrevalence In Children In Sub--SaharanSaharan

AfricaAfrica

High prevalence of infection in women ofHigh prevalence of infection in women ofchildbearing agechildbearing age

Low coverage of PMTCT interventionsLow coverage of PMTCT interventions

Lack of male partner involvementLack of male partner involvementMultiple concurrent partnersMultiple concurrent partners

Intergenerational sexual relationsIntergenerational sexual relations

PovertyPoverty

StigmaStigma

Use this slide to emphasize the

factors that contribute to the high

prevalence of HIV infection in

children in Sub-Saharan Africa.

Slide 6

Deaths Under Five Years of AgeDeaths Under Five Years of Age

Attributable to HIV/AIDSAttributable to HIV/AIDS

33.6%

36.5%

40.6%

42.2%

57.7%

4.0%

0% 10% 20% 30% 40% 50% 60%

Zambia

Namibia

Swaziland

Zimbabwe

Botswana

Global

% mortality in < 5 attributable to HIV/AIDS

F

further elaborate some of the

effects of HIV infection on child

health in Africa, using this bar-chart.

Globally 4% of deaths of childrenunder the age of 5 years are

attributable to HIV infection. In

Botswana more than half of child

mortality is attributable to HIV

infection.

Slide 7

The Link between mother The Link between mother ’’s HIV statuss HIV status

and death and child survivaland death and child survival

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0 1 2 3 4 5

age of child

c u m u l a t e d p r o b a b i l i t y o f d

y i n g

survived, HIV- survived, HIV+

dead, HIV- dead, HIV+

Nakanyngi 2002

Use this graph to demonstrate the

effect of mother’s HIV status (and

health status) on the survival forHIV-exposed or infected children.

This graph shows a direct

correlation between a mother being

alive or dead and children?s

survival. If the mother is alive,

whether she is HIV+ve or HIV-ve,

the child’s survival is improved. If

the mother was HIV+ve and died

the there is a much higher

probability of the child dying

Slide 8

Increase in number of orphanedIncrease in number of orphaned

children due to HIVchildren due to HIV

Explain the situation of orphans in

the era of the HIV epidemic using

the facts stated in the slide. Ask for

participants personal experience

Over 11.4 million orphans in subOver 11.4 million orphans in sub--SaharanSaharan

Africa have lost one or both parents to AIDS, Africa have lost one or both parents to AIDS,

constituting over 90% of the global figuresconstituting over 90% of the global figures

ProjectedProjected: By 2010 children orphaned by: By 2010 children orphaned by

AIDS will be over 25 million, globally AIDS will be over 25 million, globally


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Slide 9

Prognosis in African HIVPrognosis in African HIV--

infected Childreninfected ChildrenPoorer prognosis than in developed countries forPoorer prognosis than in developed countries for

several reasons:several reasons:

Infant survival lower in Africa in generalInfant survival lower in Africa in general

•• Malnutrition and/or povertyMalnutrition and/or poverty

•• Concurrent infections (malaria, TB, diarrhea)Concurrent infections (malaria, TB, diarrhea)

Health system are weaker Health systems are weaker •• Lack of access to health care servicesLack of access to health care services

•• Delayed laboratory diagnosisDelayed laboratory diagnosis

•• Lack of access to basic HIV care and ARTLack of access to basic HIV care and ART

Explain factors that impact on the

prognosisof HIV infected children in

Africa using the content of this slide.

Slide 10Brainstorm (5 min)

What are the modes of transmission ofHow do children get HIV infection?

HIV in Children?

Ask participants to brainstorm on

the ways through which children get

infected with HIV.

Use the next slide to summarize the

brainstorming session

Slide 12

Mother-to-child transmission

(Vertical transmission)(in an Untreated Breastfeeding Population,Total Transmission Rate is up to 30 - 45%)

- Pregnancy (womb) ---------- (5-10%)

- During birth )%51-01(-------

- Breastfeeding )%02 – 5(-----

Use this slide to consolidate

learning on vertical transmission


How can HIV infection be prevented inHow can HIV infection be prevented in

children?children?

Participants should brainstorm on

ways of preventing HIV infection in

children as one of the participants

writes their contribution on flip chartpaper.

Horizontal transimition; sexual activity,unsafe medical procedures

→

→


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Slide 14

Prevention of HIV Infection in

Children

Prevention of mother to child transmissionPrevention of mother to child transmission

(PMTCT)(PMTCT)

Promotion of abstinence & delay in sexualPromotion of abstinence & delay in sexual

debut for young peopledebut for young peoplePost exposure prophylaxis (rape, sexualPost exposure prophylaxis (rape, sexual

abuse)abuse)

Safer sex innovationsSafer sex innovations

Safer medical/surgical practicesSafer medical/surgical practices

Use this slide to summarize the

brainstorming session.

Slide 15

UNIT 2Natural Disease Progression,Natural Disease Progression,

Diagnosis and Staging inDiagnosis and Staging inChildrenChildren

Begin the unit by asking the

participants to share what they

know about HIV diseaseprogression in children.

Slide 16

How HIV Affects the Immune

SystemHIV attaches to cells of the immune system withHIV attaches to cells of the immune system with

special surface markers calledspecial surface markers called CD4CD4 receptorsreceptors

The following immune cells haveThe following immune cells have CD4CD4 receptorsreceptors•• TT--LymphocytesLymphocytes – – CD4CD4 CellsCells

•• MacrophagesMacrophages

•• MonocytesMonocytes

•• DendriticDendritic cellscells

The virus destroys and depletes theseThe virus destroys and depletes these CD4CD4 TT

lymphocyteslymphocytes -- weakening the immune system.weakening the immune system.

Use the information provided in the

following set of slides to guide the

session.

Slide 17 HIV uses the THIV uses the T--cell to make more HIVcell to make more HIV

HIV

T-CELL

HIVHIV HIV

HIV

Continue


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Slide 18 As the virus grows, many T As the virus grows, many T--cells are destroyedcells are destroyed

The T cells (CD4 cells) become depleted, weakeningThe T cells (CD4 cells) become depleted, weakeningthe immune system.the immune system.

HIV t-cell

HIVHIV

HIVHIV

HIV

HIV

HI

V

t

t

t

HIV

HIV

HIV

HIV

HIV

HIV

Continue


HIV classification: How many types of theHIV classification: How many types of the

Human Immunodeficiency Virus do youHuman Immunodeficiency Virus do youknow?know?


the different types of the HIV virus.

Slide 20

Classification of HIV

There are two types of HIV.There are two types of HIV.

HIVHIV – – 11

Is found worldwideIs found worldwide

Is the main cause of the worldwide pandemicIs the main cause of the worldwide pandemic

HIVHIV – – 22

Is mainly found in West Africa, Mozambique andIs mainly found in West Africa, Mozambique and Angola. Angola.

Causes a similar illness to HIVCauses a similar illness to HIV ?? 11

Less efficiently transmitted; rarely causing verticalLess efficiently transmitted; rarely causing verticaltransmissiontransmission

Less aggressive with slower disease progressionLess aggressive with slower disease progression

May not respond well toMay not respond well to ARVs ARVs compared to HIVcompared to HIV--11

Use the slide to summarize the

classification of HIV

Slide 21

Consequences….

Lymphocytes

T lymphocytes B lymphocytes

Helper CD4 Cytot oxic C D8

Virus, Fungus, Bacteria, Mycobacterium

Use this slide to demonstrate how

the HIV decreases CD4 cells andcauses decline in immunity, leading

to various illnesses in children.


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Slide 22Children with HIV have faster

progression of disease than adults

Emphasize that HIV disease

progression is faster in children

than in adults. Hence the need to

identify children earlier

Slide 23

HIV Disease Progression in

Children in Africa

Category 1 (25Category 1 (25 – – 30%):30%):

Rapid disease progression; infants die within 1 yearRapid disease progression; infants die within 1 year --

disease acquired indisease acquired in uteroutero (during pregnancy) or during(during pregnancy) or during

birth.birth.Category 2 (50Category 2 (50 – – 60%):60%):

Children who develop symptoms early in life.Children who develop symptoms early in life.

Deteriorate and die by 3 to 5 years.Deteriorate and die by 3 to 5 years.

Category 3 (5Category 3 (5 – – 25%):25%):

LongLong--term survivors who live beyond 8 years ofterm survivors who live beyond 8 years of

age.age.

Use slide to elaborate on the

categories of HIV disease

progression in children. Emphasizethe need to identify and start

treating children earlier.

Slide 24Group Work (20 min)

Factors predicting prognosis in childrenFactors predicting prognosis in children

Clinical presentation in childrenClinical presentation in children

Arrange for group work on:

(1) Factors predicting prognosisof HIV in children (2 groups,explore maternal and infantfactors).

(2) Clinical presentation inchildren (2 groups ? rapidand slow progressors)

Groups present their feedback and

the facilitator uses the followingsummarize and add missing

Slide 25Factors predicting prognosis

Maternal factors

Maternal disease statusMaternal disease status

Maternal viral load at deliveryMaternal viral load at delivery

Maternal CD4 ( when mother dies

Use the next slides to summarize

the presentations from the groups

slides to

factors.


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Slide 26Factors predicting prognosis

Infant factors

Immature immune systemImmature immune system

Viral load (at infection) and Infant CD4%Viral load (at infection) and Infant CD4%

Complementary and independent factorsComplementary and independent factors

Rate of decline of CD4Rate of decline of CD4

More predictive of advanced risk ofMore predictive of advanced risk of OIsOIs >1>1stst yr yr

Infant peakInfant peak viremiaviremia..

Timing of infectionTiming of infection

Clinical AIDSClinical AIDS

Children have higher CD4 counts

than adults and this varies with age,

reaching adult levels around 5-6

years. It is the CD4 T cell % thatdefines the immunological

condition. CD4100,000

copies/ml) by 2 months of age and

remain high throughout the first

year if there is no treatment.

Slide 27

Clinical presentation of rapid

progressors

Low birth weightLow birth weight

Poor growth in heightPoor growth in height

and weightand weight

Developmental delayDevelopmental delay

Persistent oral thrushPersistent oral thrush

((candidiasiscandidiasis))

Recurrent/persistentRecurrent/persistent

diarrhoeadiarrhoea

RecurrentRecurrent

bacterial/fungalbacterial/fungal

infectionsinfections

Brain dysfunctionBrain dysfunction

(encephalopathy)(encephalopathy)

Rapidly decreasingRapidly decreasing

CD4 countsCD4 counts

Use this slide to elaborate on

clinical presentation.

Slide 28

40% of infants will die of HIV

by 1 year age

Emphasize the rapid progression

and mortality in young children.

Slide 29

Clinical presentation of slow

progressors

Opportunistic InfectionsOpportunistic Infections

after 2after 2 -- 10 years10 years

Marked growth failure,Marked growth failure,

especially in heightespecially in height

Recurrent chest problemsRecurrent chest problems

(Lymphoid interstitial(Lymphoid interstitial

pneumonitispneumonitis -- LIP)LIP)

Enlargement of theEnlargement of the

parotid glandsparotid glands ?? usuallyusually

painlesspainless

Recurrent bacterial andRecurrent bacterial and

fungal infectionsfungal infections

Skin problemsSkin problems

AIDS AIDS--related cancersrelated cancers

Low viral loads at birth,Low viral loads at birth,

stable CD4 counts for 2stable CD4 counts for 2 --

10 years then slow10 years then slow

declinedecline

Elaborate on slow progressors.


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Slide 30

Diagnosis of HIV Infection in

Children

Ask participants to share knowledge

on diagnosis of HIV infection in

children is made.

Slide 31

Diagnosis of HIV Infection in

Children

Diagnosis may be made at two levels:Diagnosis may be made at two levels:

Clinical diagnosisClinical diagnosis ?? based on the symptoms andbased on the symptoms and

signs the child presents with. This should alwayssigns the child presents with. This should alwaysbe confirmed by laboratory testsbe confirmed by laboratory tests

Laboratory diagnosisLaboratory diagnosisTo confirm suspected HIV infection in a sick child orTo confirm suspected HIV infection in a sick child or

To determine HIV infection or exposure status in aTo determine HIV infection or exposure s tatus in achild with no symptomschild with no symptoms

Use slide to further elaborate on

diagnosis.

Slide 32

Laboratory Diagnosis

There are two types of laboratory tests for HIVThere are two types of laboratory tests for HIV

diagnosis:diagnosis:

(1) Antibody tests (identify antibody that the(1) Antibody tests (identify antibody that thehuman body produces against the HIV):human body produces against the HIV):?? HIV ELISA, Western blot (performed in laboratory, 4 hrs)HIV ELISA, Western blot (performed in laboratory, 4 hrs)

?? Rapid tests (Rapid tests (egeg. determine,. determine, biolinebioline,, unigoldunigold ?? performed byperformed bylab. orlab. or counsellor counsellor , may take 15, may take 15--20 minutes to have results)20 minutes to have results)

(2)(2) VirologicVirologic tests (identify HIV in blood):tests (identify HIV in blood):?? HIV PCR (DNA or RNA/viral load assay),HIV PCR (DNA or RNA/viral load assay), DBS method nowDBS method now

being used increasingly.being used increasingly.

Emphasize the types of laboratory

tests used in children.

Slide 33HIV Tests and placental transfer

of antibodies

Placenta

Unborn fetus in utero

**************

***************

***

**

Newborn

Maternal IgG

antibodies

Use slide as an illustration for how

antibodies are transferred frommother to child (through the

placenta).


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Slide 34

Therefore, all newborns are bornTherefore, all newborns are born

with maternalwith maternal IgGIgG antibodiesantibodies

0

10

20

30

40

50

60

70

80

90

100

Birth 10 mo 12 mo 15 mo

% Infants with

Antibodies

Age of infant (months)

Key point - Antibodies are not the

same as the HIV virus

Slide 35 Experience Sharing (20 min)Experience Sharing (20 min)

What tests are available in your country orWhat tests are available in your country or

work setting for diagnosis of pediatric HIV?work setting for diagnosis of pediatric HIV?

What challenges do you meet in usingWhat challenges do you meet in using

these tests?these tests?

Ask participants to share what they

know about the various tests

available for testing for pediatric

HIV infection.

Slide 36Laboratory diagnosis in childrenLaboratory diagnosis in children

< 18 mo age< 18 mo age

Antigen (viral) tests Antigen (viral) tests

DNA PCR (wholeDNA PCR (wholeblood or DBS)blood or DBS)

RNA PCRRNA PCR

> 18 mo age> 18 mo age

Antibody (serology) Antibody (serology)

teststestsRapidRapid

ELISAELISA

Follow the laboratory test algorithm in your setting/country

Summarize participants’

experiences with pediatric diagnosis

using this slide. Use the responsesshared to discuss the practical

challenges. Emphasize the need for

clear explanations to mothers

during PMTCT.

Slide 37

Signs/symptoms ofSigns/symptoms of ““possiblepossible”” HIVHIV

infection in a childinfection in a child

Presence of 3 or more of the following:Presence of 3 or more of the following:TB in any parent in the last 5 yearsTB in any parent in the last 5 years

Pneumonia (now or previously)Pneumonia (now or previously)2 or more episodes of2 or more episodes of diarrhoeadiarrhoea that lasted >14 daysthat lasted >14 days

Growth faltering or very low weight for age ( below theGrowth faltering or very low weight for age ( below the??very low weight curvevery low weight curve??on childon child--health card)health card)

Enlarged lymph nodes in 2 or more of the following sitesEnlarged lymph nodes in 2 or more of the following sites(neck,(neck, axillaaxilla, groin), groin)

Oral thrushOral thrush

* This is a method of making a clinical diagnosis of HIV in chil* This is a method of making a clinical diagnosis of HIV in childrendrenunder age of 5 yearsunder age of 5 years – – these signs should prompt an HIV testthese signs should prompt an HIV test

* Any child whose parent is HIV* Any child whose parent is HIV--positive or has died from an HIVpositive or has died from an HIV--related illness should be screened for HIV infectionrelated illness should be screened for HIV infection

Highlight clinical diagnosis using

signs and symptoms of HIV in

children.


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Slide 38 Brainstorm (10 min)Brainstorm (10 min)

What are theWhat are the ?points of entrypoints of entry ?forfor

identifying children who need to be testedidentifying children who need to be tested

for and provided HIV services?for and provided HIV services?


points of entry within the health

system and community for HIV

diagnosis in children

Slide 39

Points of EntryPoints of Entry

Test mothers who deliver without prior testing for HIVTest mothers who deliver without prior testing for HIV

Paediatric wards: providing HCT to children admitted forPaediatric wards: providing HCT to children admitted forvarious illnesses.various illnesses.

Outpatient clinicsOutpatient clinics

TB wards (adults/children).TB wards (adults/children).

Nutrition Rehabilitation Units (NRU)Nutrition Rehabilitation Units (NRU)

Sexually abused children/exposed to potentially infectiousSexually abused children/exposed to potentially infectiousbody fluidsbody fluids

Adolescent clinics Adolescent clinics

Community Diagnosis;Community Diagnosis; OVCsOVCs programs/ orphanages,programs/ orphanages,schoolsschools

? < 5 clinics? < 5 clinics

Use slide to help consolidate

learning.

Slide 40

Staging of HIV DiseaseStaging of HIV Disease

in Childrenin Children

Use the next set of slides to

describe the staging of HIV disease

in children.

Slide 41

The Importance of StagingThe Importance of Staging

Provides a guide to the timing of initiationProvides a guide to the timing of initiation

of ARTof ART

Provides a guide to interventions neededProvides a guide to interventions needed

at the different stages of the disease, andat the different stages of the disease, andpossible outcomespossible outcomes

Provides guidance in monitoring responseProvides guidance in monitoring response

to therapy (treatment failure orto therapy (treatment failure or

improvement).improvement).

Emphasize the importance of

staging using this slide.


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Slide 42

Methods of StagingMethods of Staging

Clinical staging:Clinical staging:

-- WHO stagingWHO staging

Immunological stagingImmunological staging-- CD4 countCD4 count

Highlight the methods of staging.

Slide 43

WHO classification of HIVWHO classification of HIV--

associatedassociated clinicalclinical diseasedisease

Severe 4Severe 4

Advanced 3 Advanced 3

MildMild 22

Asymptomatic 1 Asymptomatic 1

Classification ofClassification of

HIV disease WHO StageHIV disease WHO Stage

Using this slide to describe the 4

WHO clinical stages and how they

relate to the classification of

disease severity.

Slide 44

UNIT 3UNIT 3

Primary Care andPrimary Care andManagement of the HIVManagement of the HIV

positive childpositive child

This unit describes the primary care

and management of the HIV

positive child.

Slide 45Brainstorm (10 min)Brainstorm (10 min)

What is the followWhat is the follow--up protocol for HIVup protocol for HIVexposed infants in your program/country ?exposed infants in your program/country ?


know about the follow-up protocolor standard of HIV exposed infants

in their programs.

Record answers on a flip chart


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Slide 46Follow-up of HIV exposed

children

Children born to mothers who are HIVChildren born to mothers who are HIV--

positive need regular clinical monitoringpositive need regular clinical monitoring

Monthly in the first year of lifeMonthly in the first year of life

Regularly during childhoodRegularly during childhoodLook out forLook out for “ “slowslow progressorsprogressors

Use the slide to emphasize the

need to have a well planned follow-

up system for HIV exposed

children.


What are the components ofWhat are the components of

comprehensive HIV management incomprehensive HIV management in

children?children?


the components of comprehensive

pediatric HIV management.

Record answers on a flip chart

Slide 48Summary - Care of the HIV infected Child

10 pillars of comprehensive care in HIV10 pillars of comprehensive care in HIV

infected children:infected children:

1.1. Confirmation of HIV diagnosisConfirmation of HIV diagnosis

2.2. Staging of DiseaseStaging of Disease

3.3. Treatment of acute infections and otherTreatment of acute infections and other OIOI??ss

4.4. ImmunizationImmunization

5.5. Regular monitoring of growth andRegular monitoring of growth and

developmentdevelopment

6.6. Nutritional care, supplementation and adviceNutritional care, supplementation and advice

Summarize the package using

information on this slide.

Slide 49

Summary - Care of the HIV infected

Child (2)

10 Pillars Cont10 Pillars Cont’’d:d:

7. Prevention of infections e.g. PCP7. Prevention of infections e.g. PCP

((cotrimoxazolecotrimoxazole), Malaria, Diarrhoea), Malaria, Diarrhoea

8. Counselling for and providing ART.8. Counselling for and providing ART.

9. Providing care, treatment and psychosocial9. Providing care, treatment and psychosocial

support for mother and familysupport for mother and family

10. Planning for/providing follow up including10. Planning for/providing follow up including

community supportcommunity support

Cont.


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Slide 50

Primary Care of HIV infected

children - Immunization

Asymptomatic HIV+ children should be Asymptomatic HIV+ children should be

vaccinated exactly in the same manner asvaccinated exactly in the same manner as

HIV uninfected childrenHIV uninfected children

BUTBUTSymptomatic (Stages 3Symptomatic (Stages 3 -- 4) HIV+ children4) HIV+ children

should not be given BCG or yellow fevershould not be given BCG or yellow fever

vaccinevaccine

Use the next set of slides to explain

some of the components of the care

package.

Slide 51

Growth MonitoringSlow growth may indicate presence of HIVSlow growth may indicate presence of HIVinfectioninfection

Monitoring growth enablesMonitoring growth enables early detection ofearly detection ofHIV infectionHIV infection

Growth failure is more common in HIV infectedGrowth failure is more common in HIV infected

children because of:children because of:Increased energy needs.Increased energy needs.Other underlying diseasesOther underlying diseases ( ( e.ge.g TB, repeated diarrheaTB, repeated diarrheaetc )etc )

Inadequate food intake.Inadequate food intake.

Weight, height should be measured andWeight, height should be measured andmonitored at every visit.monitored at every visit.

Emphasize the role of growth

monitoring.

Slide 52

Nutrition in HIV infected children

Includes the following broad areas:Includes the following broad areas:

1.1. First 6 months of lifeFirst 6 months of life ?? breastfeeding orbreastfeeding orreplacement feedingreplacement feeding

2.2. Complementary feeding from 6 monthsComplementary feeding from 6 months3.3. Micronutrient supplementsMicronutrient supplements

4.4. Extra feeding during and after periods ofExtra feeding during and after periods ofillnessillness

5.5. Advising the mother to keep up with child Advising the mother to keep up with childhealth visitshealth visits

Highlight the various aspects of

nutrition that need attention.

Slide 53Causes of poor nutrition in HIV

infected childrenInadequate intakeInadequate intake

PersistentPersistent diarrhoeadiarrhoeaPoor appetitePoor appetite

Recurrent infectionsRecurrent infections

Mouth sores (Mouth sores (egeg. oral thrush, herpes). oral thrush, herpes)

Underlying chronic illness (Underlying chronic illness (egeg; TB); TB)

Let participants share the causes

and their experiences of poor

nutrition in HIV infected children,and then use this slide to

summarize.


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Slide 54Treating HIVTreating HIV--related Diseasesrelated Diseases

Diseases that complicate HIV infectionDiseases that complicate HIV infection

1.1. Infections that are commonly seen even in HIVInfections that are commonly seen even in HIVnegative children (such as common chestnegative children (such as common chestinfections, ear infections, diarrhoea, malariainfections, ear infections, diarrhoea, malariaetc)etc)

2.2. Opportunistic infections (Opportunistic infections (OIsOIs))?? Rare in HIV negative childrenRare in HIV negative children?? Occur when immunity of child weakensOccur when immunity of child weakens

?? E.g. TB, oralE.g. TB, oral candidacandida, atypical (unusual) pneumonia, atypical (unusual) pneumonia-- PCPPCP

3.3. Cancers e.g. Kaposi's, lymphoma etcCancers e.g. Kaposi's, lymphoma etc

4.4. Diseases of organs e.g. heart, kidney, liver etcDiseases of organs e.g. heart, kidney, liver etc

Use slide to emphasize the

importance of ensuring timely and

appropriate treatment of the various

HIV-related diseases.

Slide 55

The Dual EpidemicThe Dual Epidemic

HIV TB

33.3 Million 2 Billion

WHO/UNAIDS estimates - 2006

Highlight on the interaction between

HIV and TB

Slide 56

The rise of TB in Africa – linked to HIV

0

50

100

150

200

250

300

350

400

1980 1985 1990 1995 2000

S t a n d a r d i z e d

T B c

a s e

n o t i f i c a i t o n

r a t e

Continue

Slide 57

TuberculosisTuberculosis

TB and HIV commonly coTB and HIV commonly co--exist; 12exist; 12-- 60 % of60 % ofchildren diagnosed with TB also have HIVchildren diagnosed with TB also have HIV

Children with HIV are between 5Children with HIV are between 5--10 times10 timesmore likely to develop TBmore likely to develop TB

Children with dual infection of TB and HIV areChildren with dual infection of TB and HIV are4 times more likely to die4 times more likely to die

In most children it presents as chest TB but itIn most children it presents as chest TB but itmay involve other parts of the bodymay involve other parts of the body

Treatment should follow national guidelinesTreatment should follow national guidelines

Continue


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Slide 58

Prevention of HIV-related

Infections

CotrimoxazoleCotrimoxazole prophylaxis (CTZ)prophylaxis (CTZ)

Prevents PCP, bacterial infections and malariaPrevents PCP, bacterial infections and malaria

Proven to greatly reduce frequency ofProven to greatly reduce frequency of

illnesses in HIV infected childrenillnesses in HIV infected children

?? All children born to HIV infected women should receive All children born to HIV infected women should receiveCTZ prophylaxis from age of 6 weeks until HIV is ruledCTZ prophylaxis from age of 6 weeks until HIV is ruled

out.out.

?? Those confirmed to be HIV infected should continueThose confirmed to be HIV infected should continue

CTZ prophylaxis according to specific national or WHOCTZ prophylaxis according to specific national or WHO

recommendations.recommendations.

Use this slide to summarize

prevention of some HIV related

diseases.

Slide 59Key counseling considerations

for OIs

HIV is not AIDS;HIV is not AIDS; OIsOIs can affect the childcan affect the child??ss

health but are preventable/ treatablehealth but are preventable/ treatable

Child presenting with an OI needsChild presenting with an OI needs

evaluation for possible ARTevaluation for possible ART

Guardians/parents need education to offerGuardians/parents need education to offer

appropriate support to the childappropriate support to the child

Highlight on key issues counselors

should know about OIs.

Support needed includes healthcare, nutrition and psychosocial.

Slide 60Monitoring the status of HIV

infection

The CD4 countThe CD4 count

CD4+CD4+ Tcells/Tcells/μμll

Measures ability toMeasures ability to

keep ahead of HIVkeep ahead of HIV

infectioninfection

Predicts risk ofPredicts risk of

opportunistic infectionopportunistic infection

Predicts risk of deathPredicts risk of death

The viral loadThe viral load

HIV RNA copies/mlHIV RNA copies/ml

Measures level ofMeasures level ofinfectioninfection

Predicts CD4 declinePredicts CD4 decline

Predicts risk ofPredicts risk ofopportunistic infection &opportunistic infection &other complicationsother complications

Predicts risk of deathPredicts risk of death

Provide a brief highlight on the use

of laboratory tests to monitor HIV

disease in children.

Slide 61

Unit 4

Basics of ART inBasics of ART in

ChildrenChildren


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Slide 62

Objective

Explain the fundamentals of antiretroviralExplain the fundamentals of antiretroviral

treatment in childrentreatment in children

Identify the differences between ART forIdentify the differences between ART for

children and adultschildren and adults

Use slide to outline the objectives for

this unit.

Slide 63Goals of Antiretroviral Therapy

Maximal and durable suppression of HIVMaximal and durable suppression of HIVreplicationreplication

Restoration and preservation of immuneRestoration and preservation of immunefunctionfunction

Restoration of normal growth andRestoration of normal growth and

developmentdevelopmentReduction of HIV related illnesses andReduction of HIV related illnesses anddeathdeath

Improved quality of lifeImproved quality of life


know about the goals of ART

Use slide to summarize the goals

Slide 64

When to start ART

When medically necessary / indicatedWhen medically necessary / indicated

When other medical problems areWhen other medical problems areaddressed e.g.addressed e.g. OIsOIs treatedtreated

When adherence potential and barriersWhen adherence potential and barriers

are assessedare assessedWhen major adherence barriers areWhen major adherence barriers areaddressedaddressed

When family is motivated and readyWhen family is motivated and ready

When stable drug supply is assuredWhen stable drug supply is assured

Explain what ART means

Outline when it is suitable to begin

ART in children.

Slide 65 Advantages of Starting ART

Earlier Earlier

Prevent CD4 declinePrevent CD4 decline

Prevent infectionPrevent infection

Protect brain & otherProtect brain & otherorgansorgans

Preserve immunePreserve immuneresponse to HIV (HIVresponse to HIV (HIVimmune responseimmune responsedoes not improve ondoes not improve ontherapy)therapy)

Later Later

Avoid toxicity, side Avoid toxicity, side--effects, and costeffects, and cost

Avoid resistance Avoid resistance

Children generallyChildren generally

respond very well torespond very well to ART ART


importance of starting ART at

the appropriate time.


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Slide 66

WhenWhen not not to start HAARTto start HAART

When adherence potential and barriers notWhen adherence potential and barriers not

assessedassessed

When major adherence barriers remainWhen major adherence barriers remain

When family not motivated and readyWhen family not motivated and ready

When stable drug supply not assuredWhen stable drug supply not assured

When other medical problems create risk:When other medical problems create risk:

e.g. active, untreated TB or acute PCPe.g. active, untreated TB or acute PCP

Explain some conditions that may

warrant delay in initiation of ART

Slide 67How good must adherence be?How good must adherence be?

Generally > 95% of dosesGenerally > 95% of doses

Some treatment regimens are moreSome treatment regimens are more “ “forgivingforgiving” ” than others: D4T/3TC/NVP is a lessthan others: D4T/3TC/NVP is a less “ “forgivingforgiving” ” regimenregimen-- but can work excellently for years ifbut can work excellently for years if

adherence is maintained.adherence is maintained.

Missing 1 dose per week is 93% adherenceMissing 1 dose per week is 93% adherence

Adherence < 80% almost always fails Adherence < 80% almost always fails

“ “GoodGood” ” adherence takingadherence taking “ “mostmost” ” doses will leaddoses will leadto failureto failure

RareRare missed dose is toleratedmissed dose is tolerated

Use this slide to highlight some

basic facts about adherence.

Slide 68Major classes ofMajor classes of antiretroviralsantiretrovirals

Reverse transcriptase inhibitorsReverse transcriptase inhibitors

Nucleoside analogue reverse transcriptaseNucleoside analogue reverse transcriptase

inhibitors:inhibitors: NRTIsNRTIs

NonNon--nucleoside reverse transcriptasenucleoside reverse transcriptase

inhibitors:inhibitors: NNRTIsNNRTIs

HIV protease inhibitors: PIsHIV protease inhibitors: PIs

Explain major classes of ARV drugs

available in practice.

Slide 69

TARGET SITES FOR ARV DRUGSTARGET SITES FOR ARV DRUGS

HIVparticle

Injectionof

contents

HOST CELL

Binding

Binding

sites

RNADNA

Reverse

transcription Transcription

Integration of provirusDNAinto host DNA

Translation

Cell

membrane

Completed

HIVparticle

Maturation

Budding

Viral

assembly

Protein

cleavage

gp41 gp120

RNAs

e

Protease

IntegraseProvirus(circular structure)

ProteaseInhibitors workhere

NRTI’s &

NNRTI’swork here

Fusioninhibitors

workhere

CD4Cell

HIVParticle

Integrase

Inhibitor

s

Use this pictorial to explain in

simple terms the areas where

various ARV drugs work in the life

cycle of the HIV.


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Slide 70

Common antiretroviral drugs used to treatCommon antiretroviral drugs used to treat

childrenchildren -- 20072007

Reverse transcriptaseReverse transcriptase

Inhibitors:Inhibitors:

-- Nucleoside RTINucleoside RTI

ZidovudineZidovudine

StavudineStavudine

LamivudineLamivudine

Abacavir Abacavir

-- NonNon--nucleoside RTInucleoside RTI

NevirapineNevirapine

EfavirenzEfavirenz

Protease inhibitors

Lopinavir/ritonavir (Kaletra)

Nelfinavir

Give examples of the various ARVs

used to treat children

Slide 71 ARV Drugs ARV Drugs – – SpecialSpecial

Considerations in ChildrenConsiderations in Children

Palatability (taste of drug)Palatability (taste of drug)

Syrups are generally bulkier Syrups are generally bulkier -- Fluid volume, refrigerationFluid volume, refrigeration

Ability to split, crush, mix and administer tablets/capsules Ability to split, crush, mix and administer tablets/capsules

Potency, pediatric experience, pharmacokineticPotency, pediatric experience, pharmacokineticinformationinformation

Regimen complexityRegimen complexity -- dosing frequency, food and fluiddosing frequency, food and fluidrequirementsrequirements

Presence of other infections that could affect drug choicePresence of other infections that could affect drug choice-- TB, Hepatitis B or C or chronic renal or liver diseaseTB, Hepatitis B or C or chronic renal or liver disease

Highlight on some special issues

that have to be taken into

consideration when ARV drugs are

given to children

Slide 72

Viral LoadViral Load

You want the viral load to beYou want the viral load to be LOW!LOW!

HIVHIV

HIV

HIV HIV

HIV

HIV

HIV

HIV

HIV


need to lower the viral load to

ensure good health

Slide 738 Steps to ART success in children8 Steps to ART success in children

1.1. IdentifyIdentify child for whom benefits outweigh risks (andchild for whom benefits outweigh risks (andlocal guidelines permit therapy)local guidelines permit therapy)

2.2. AssessAssess prior adherence, all potential adherenceprior adherence, all potential adherencebarriersbarriers

3.3. ImplementImplement solutions to adherence barrierssolutions to adherence barriers4.4. EducateEducate family and child about HIV & HAARTfamily and child about HIV & HAART

5.5. SelectSelect treatment that istreatment that is potent, durable, convenient,potent, durable, convenient,nonnon--toxic, welltoxic, well--tolerated, and sustainabletolerated, and sustainable

6.6. TrainTrain family and child on dosing and schedulefamily and child on dosing and schedule

7.7. Monitor Monitor response and adherenceresponse and adherence

8.8. RespondRespond promptly to problemspromptly to problems

Summarize the steps that enable

ART success in children

Allow for a lot of discussion by the

participants on how to maximize

success of ART in children in their

programs.


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Slide 74

If yourIf your TT--cellscells areare highhigh and yourand your ViralViral

LoadLoad isis lowlow, you can be, you can be healthyhealthy for afor a

very long timevery long time

HIV

t

Use slide as an illustration for the

benefits of ART: lowering viral load

and allowing for increase in CD4

count to ensure healthy.

Slide 75

These children can live to pursue their dreams!

We want ART to be successful so

that the child can be healthy and

experience life to the fullest


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MODULE OBJECTIVES

At the end of this module the participants will be able to:

1. Explain main components of Child Development2. Describe the factors contributing to abnormal development3. Identify abnormal development associated with HIV infection

NOTES

This module consists of 3 units which cover various aspects of child development. Themethods used in delivery of this module for all the 3 units include lecture/group discussions,experience sharing and brainstorming. Understanding the various stages of child developmentis important in order to determine the appropriate counseling techniques that can be used.

SUGGESTED TRAINERSThis module is best taught by health care providers or pyschologists/social workers with experience in

working with children.

Outline of Module 2: Child Development

Time

1½hrs

Objectives Content Teaching/learning

methods/activitie

s

Resource

materials

45

mins

Unit 1:Explain the maincomponents of childdevelopment

NormalDevelopmentdomains:Cognitive,social/emotional;motor and language

Brainstorming;

lecture/discussions

MS Power Point

Slides, flip charts

and markers

15

mins

Unit 2:

Describe factors

contributing to

abnormal

development

Prenatal, Natal ,

Postnatal factors

Brainstorming,

Lecture discussion.

Slides, flip charts

and markers

30mins

Unit 3:Identify abnormaldevelopment

Indicators, effects ofHIV on developmentof young brain ,assessment andrecognition ofabnormaldevelopment

Brainstorming,Lecture discussion

Slides, flip chartsand markers

MODULE 2:

CHILD DEVELOPMENT


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Module 2: Slides and Instructions for Facilitators

Slide 1Module 2Module 2

Child DevelopmentChild DevelopmentChild Development

Slide 2

AIDSRelief AIDSRelief -- ANECCA Counseling forChildren and Adolescents affected byHIV ANECCA Counseling forChildren and Adolescents affected byHIV

ObjectivesObjectives

Explain main components of ChildExplain main components of Child

DevelopmentDevelopment

Describe factors contributing to abnormalDescribe factors contributing to abnormal

development.development.

Identify abnormal development associatedIdentify abnormal development associated

with HIV infectionwith HIV infection

Use this slide to outline the moduleobjectives

Slide 3

Unit 1Unit 1

Main Components of childMain Components of child

developmentdevelopment

Slide 4


Child development follows anChild development follows an

orderly progressionorderly progression

Use this slide to emphasize that

child development is an orderly

progression of skills. It allows for

increasing independence and

autonomy.

Note: Analogy is not exactly the

same because as a child moves

from stage to stage he or she

always builds on the previous

stage, whereas in the development

of a butterfly, there are definitive


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Slide 8

Motor DevelopmentMotor Development

Use the following set of slides to

elaborate on motor development

Slide 9


Continue

Slide 10


Continue

Slide 11


Cognitive DevelopmentCognitive Development

Use the following set of slides to

elaborate on cognitive domain

development.


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Slide 16


PrePre--operational thoughtoperational thought

Use the content of this slide to

elaborate on the stage of pre-

operational thought. The child is

very ego-centric at this stage.

Slide 17


Concrete & Formal OperationalConcrete & Formal Operational

StagesStages

Concrete operational stage:Concrete operational stage:

Reason logically about concrete objects &Reason logically about concrete objects &events, but does not reason in abstract termsevents, but does not reason in abstract terms

Formal operational stage:Formal operational stage:

Can reason about abstract/hypotheticalCan reason about abstract/hypothetical

situationssituations

Examples of concrete operational

stage: For example recount what

they did in school, but cannotappreciate the cause and effect e.g.

that the teacher was angry or

annoyed. Or, children blaming

themselves over what happened

e.g. the mother is unwell, and they

may think they are responsible. My

mother asked me to bring a cup and

I didn’t and that is why she is sick.

Formal operational stage: If I don’t

take my drugs, then I will fall sick

and even die. If I refuse to eat, my

mother will get angry.

Slide 18


Role of playRole of play

Early means of learning how to connectEarly means of learning how to connect

with the environment and peoplewith the environment and people

Way of sharing, expressing needs andWay of sharing, expressing needs and

feelingsfeelings

How children first learn societal rules,How children first learn societal rules,

norms & customsnorms & customs

Teaches role recognitionTeaches role recognition

Intellectual developmentIntellectual development


importance of play for children. For

example:

Playing family, carrying babies.

Playing with sand and water.

All children around the world play,

but may use different play materials

and not just toys bought from

shops.


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Slide 19


The Role of AttachmentThe Role of Attachment

Attachment is the emotional bond between a Attachment is the emotional bond between a

child and other important persons in their liveschild and other important persons in their lives

It provides for aIt provides for appropriate socialization andppropriate socialization and

development of relationshipsdevelopment of relationshipsIt helps children to develop intellectuallyIt helps children to develop intellectually

Helps in mood regulationHelps in mood regulation

In order for children to develop

properly, they need nurturing

relationships.

The breakdown of families due to

HIV is denying the opportunities to

develop these relationships which

are important to children’s quality of

life and healthy development..

Slide 20

LanguageLanguage

DevelopmentDevelopment

Slide 21


Language DevelopmentLanguage DevelopmentPrelinguisticPrelinguistic periodperiod

Newborns distinguish the sound of humanNewborns distinguish the sound of human

voicevoice

6

facil. manual_paed hiv counseling curric

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