ppediatric hiv june06
TRANSCRIPT
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Module 7: Paediatric HIV, KMA
Management of HIV infected Children
KMA CurriculumModule 7June 2006
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Module 7: Paediatric HIV, KMA
Objectives To outline the epidemiology of HIV in children To describe various modes of HIV transmission to
children. To discuss the natural disease progression of HIV in
children. Outline diagnostic criteria for paediatric HIV –
laboratory as well as clinical. To impart knowledge on prevention and treatment of
common HIV related conditions in HIV infected children
To describe how and when to provide antiretroviral therapy in children, , including initiation, pre-ART preparation, monitoring, when to change/withdraw ART.
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Module 7: Paediatric HIV, KMA
Epidemiology and HIV transmission in Children
Unit 1Management of HIV infected
Children
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Module 7: Paediatric HIV, KMA
Epidemiology - Kenya 1 million live births in Kenya annually 8% born to HIV infected mothers Without PMTCT 30% of these become
infected About 24,000 neonates acquire HIV
annually About 12,000 (50%) die within first 2 years HIV has had a negative impact on infant
survival
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Module 7: Paediatric HIV, KMA
Modes of HIV transmission to Children
Mother to child transmission – 95% of paediatric infections Intrauterine During delivery During breastfeeding
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Module 7: Paediatric HIV, KMA
Mother to Child HIV Transmission
30% babies born to HIV+ womenbecome infected through MTCT
5% intrauterine
10-20% during delivery
10-20% via breastfeeding
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Module 7: Paediatric HIV, KMA
Modes of HIV transmission to Children
Horizontal transmission - < 5% of paediatric infections Sexual transmission Transfusion of blood and blood products Exposure to other body fluids Use of contaminated needles and other
skin piercing/cutting instruments (circumcision, uvulectomy).
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Module 7: Paediatric HIV, KMA
Natural history of HIV in Children
Unit 2:Management of HIV infected
Children
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Module 7: Paediatric HIV, KMA
Natural history – patterns of disease progression in African children
HIV disease progresses at differing rates in children
Rapid progressors (25 – 30%): Develop AIDS and die within 1-2 years. Disease acquired in utero or perinatally.
Intermediate progressors (50 – 60%): Children who develop symptoms early in life. Deteriorate and die by 3 to 5 years.
Slow progressors (5 – 25%): Long-term survivors who live beyond 8 years of age.
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Module 7: Paediatric HIV, KMA
Natural history – patterns of disease progression in African children
Slow Progressors Low viral loads at birth Stable CD4 counts for 2-
10 years Growth stunting Initial year(s) well,
opportunistic infections as disease progresses
Encephalopathy rare
Rapid Progressors High viral load at birth Rapidly declining CD4 Low Birth Weight Chronically unwell first
year Persistent or recurrent
diarrhea Recurrent bacterial and
fungal infections Severe encephalopathy
before 18 months
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Module 7: Paediatric HIV, KMA
Natural History – Immunological changesImmunologic Parameters Absolute CD4 count higher in healthy
children than in adults. Absolute CD4 count declines steadily
during the first 5 yrs in healthy children to achieve adult levels by age 6
CD4 percentage does not change with age.
In children < 6 yr CD4 percentage is the preferred immunological parameter for monitoring disease progression.
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Module 7: Paediatric HIV, KMA
Natural History – Immunological changes
Age-related Decrease in CD4+ Number
0
2000
4000
6000
Age in Months
CD
+ N
umbe
r/m
m3
5th percentile
95th percentile
4 12 24 6090
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Module 7: Paediatric HIV, KMA
Natural History – Immunological changes
Age-related Decrease in CD4+ Percentage
0
20
40
60
80
Age in Months
CD
4+
% 5th percentile
95th percentile
4 12 24 6090
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Module 7: Paediatric HIV, KMA
Natural History – Viral load patterns in children
The HIV viral load (RNA) pattern in perinatally infected infants differs from infected adults.
Among infants infected before the age of 1 month:
Viral load (RNA) levels are zero or low at birth.
Increase to high levels above 100,000 copies/ml by 3-6 months of age.
Thereafter RNA declines slowly over several years to “set point”.
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Module 7: Paediatric HIV, KMA
Clinical signs & conditions suggestive of HIV infection in a child
Very specific for HIV infection: Oesophageal candidiasis Herpes zoster (shingles) Pneumocystis carinii pneumonia Extrapulmonary cryptococcosis Kaposi’s sarcoma
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Module 7: Paediatric HIV, KMA
Clinical signs & conditions suggestive of HIV infection in a child
Common in HIV, uncommon in HIV uninfected child
Recurrent severe bacterial infection Persistent or recurrent oral thrush Parotid enlargement Generalized lymphadenopathy Hepatosplenomegaly (non-malaria
areas) Persistent or recurrent fever Neurologic dysfunction
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Module 7: Paediatric HIV, KMA
Clinical signs & conditions suggestive of HIV infection in a child
Common in both HIV+ and HIV- children
Otitis media - persistent or recurrent Diarrhoea – persistent or recurrent Severe pneumonia Tuberculosis Failure to thrive Persistent dermatitis
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Module 7: Paediatric HIV, KMA
Diagnosis and Staging of HIV in Children
Unit 3Management of HIV infected
Children
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Module 7: Paediatric HIV, KMA
DIAGNOSIS OF PEDIATRIC HIV
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Module 7: Paediatric HIV, KMA
Clinical DiagnosisIMCI definition of symptomatic HIV
infectionPresence of 3 or more of the following: TB in any parent in the last 5 years Pneumonia (now or previously) 2 or more episodes persistent diarrhoea (>14 days) Growth faltering or weight < 3rd centile
(below “very low weight curve” in card Enlarged lymph nodes in 2 or more of the following
sites (neck, axilla, groin) Oral thrush
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Module 7: Paediatric HIV, KMA
Clinical suspicion of pediatric HIV Using IMCI tool one can easily
identify children highly likely to have HIV infection.
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Module 7: Paediatric HIV, KMA
Laboratory DiagnosisChild < 18 monthsChild < 18 months, HIV Ab may come from: Maternal Ab passively transferred to infant
maternal Ab may persist in her infant up to 18 months
so Ab test is +ve in ALL children born to HIV+ women, including those that are NOT infected (gives false +ve results)
Infant generated Ab if infant is HIV infected.
A positive HIV Ab test at this age is therefore not diagnostic, only shows child has been HIV exposed
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Module 7: Paediatric HIV, KMA
Laboratory DiagnosisChild < 18 months Need to do Virologic test – detect HIV virus
in blood
Various types:- RNA PCR - most available, also gives viral load- DNA PCR – not widely available- P24 antigen (immune-complex dissociated)
When to do virologic test: Not BF: test at age 1 month repeat 3 months later BF: wait until 3 months after cessation of BF to
confirm final HIV status.
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Module 7: Paediatric HIV, KMA
Diagnosis – combining lab and clinical criteria May not have access to PCR as is
not widely available or affordable. You can still make a diagnosis in
child < 18 months combining simple lab and clinical parameters.
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Module 7: Paediatric HIV, KMA
HIV Diagnosis before age 18 mth without virologic test
Must fulfil the following 3 criteria: WHO stage 3 or 4
PLUS HIV ELISA positive (child or mother)
PLUSCD4 < 25% (or CD4 count < 1500)(OR TLC < 3400)
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Module 7: Paediatric HIV, KMA
Diagnosis
After 18 months: HIV ELISA antibody test By 18 months, maternal
antibodies have cleared
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Module 7: Paediatric HIV, KMA
DIAGNOSIS - summary In children < 18 months HIV is diagnosed by 2
positive virological tests performed on blood samples taken on 2 separate dates.
HIV is excluded by 2 or more negative virological tests at >age 1 month, one of which is performed at age >4 months in a non-breastfed infant
If BF wait 3 months after cessation of BF
Antibody tests: 2 or more antibody tests after 18 months confirm or exclude diagnosis.
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Module 7: Paediatric HIV, KMA
STAGING PEDIATRIC HIV
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Module 7: Paediatric HIV, KMA
Clinical Staging
TWO international clinical staging systems:
World Health Organisation (WHO)Four stages – 1, 2, 3, 4
Centres for Disease Control (CDC)Four stages – N, A, B, C
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Module 7: Paediatric HIV, KMA
Disease Staging Limitations of Staging Systems
WHO Does not include immunological Does not capture some diagnoses
CDC Assumes availability of advanced
diagnostic technology Some conditions seen in resource-limited
settings not included
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Module 7: Paediatric HIV, KMA
Clinical Staging
Stage WHO CDC
Asymptomatic 1 N
Mild 2 A
Moderate 3 B
Severe (AIDS) 4 C
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Module 7: Paediatric HIV, KMA
WHO clinical staging
STAGES 1 – asymptomatic 2 – mildly symptomatic 3 – moderately symptomatic 4 – severely symptomatic (AIDS)For use in those 12 years or under
with confirmed laboratory evidence of HIV infection
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Module 7: Paediatric HIV, KMA
WHO Clinical Staging – stage 1
Stage I Asymptomatic Persistent generalized
lymphadenopathy (PGL) Hepatosplenomegaly
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Module 7: Paediatric HIV, KMA
WHO Clinical Staging - stage 2
Papular pruritic eruptions Seborrheic dermatitis Fungal nail infections Angular cheilitis Linear gingival erythema Extensive HPV or molluscum infection (>5% of
body area/face) Recurrent oral ulcerations (>2 episodes/g mos) Parotid enlargement Herpes zoster (>1 episode/12 mos) Recurrent or chronic upper respiratory infection
(URI): otitis media, otorrhea, sinusitis (>2 episodes/6 mos)
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Module 7: Paediatric HIV, KMA
WHO Clinical Stage 2
Mild conditions of the: Skin - Papular pruritic eruptions,
seborrheic dermatitis, fungal nail infections
Upper resp tract Mouth
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Module 7: Paediatric HIV, KMA
WHO Clinical Staging – Stage 3 Unexplained moderate malnutrition (-2SD
or Z score) not responding to standard therapy
Unexplained persistent diarrhea (>14 days) Unexplained persistent fever (intermittent
or constant, > 1mo) Oral candidiasis (outside neonatal period) Oral hairy leukoplakia Pulmonary tuberculosis Severe recurrent presumed bacterial
pneumonia (>2 episodes/12 mos)
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Module 7: Paediatric HIV, KMA
WHO Clinical Staging – Stage 3 (continued) Acute necrotizing ulcerative
gingivitis/periodontitis Lymphoid interstitial pneumonitis (LIP) Unexplained anemia (<8g/dL),
neutropenia (<1000/mm3), or thrombocytopenia (<30,000/mm3) for >1 mo.
HIV-related cardiomyopathy HIV-related nephropathy
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Module 7: Paediatric HIV, KMA
WHO stage 4 – all agesConditions where a presumptive diagnosis can be made using
clinical signs or simple investigations: Unexplained severe wasting or severe malnutrition not
adequately responding to standard therapy Pneumocystis pneumonia Recurrent severe presumed bacterial infections (2 or >
episodes within one year e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia )
Chronic orolabial or cutaneous Herpes simplex infection (of more 1 month duration)
Extrapulmonary tuberculosis Kaposi's sarcoma Oesophageal Candida CNS Toxoplasmosis HIV encephalopathy
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Module 7: Paediatric HIV, KMA
WHO stage 4 – all ages (continued)Conditions where confirmatory diagnostic testing is
necessary: CMV infection (CMV retinitis or infection of organ other
than liver, spleen, or lymph nodes onset at age 1 month or more)
Cryptococcal meningitis (or other extrapulmonary disease)
Any disseminated endemic mycosis(e.g. extra-pulmonary Histoplasmosis, Coccidiomycosis, Penicilliosis)
Cryptosporidiosis Isosporiasis Disseminated non-tuberculous mycobacteria infection Candida of trachea, bronchi or lungs Acquired HIV related recto-vesico fistula
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Module 7: Paediatric HIV, KMA
WHO – Stage 4: Child < 18 mths - when PCR testing not availablePresumptive Stage 4 diagnosis in children less than
eighteen months old where virological confirmation of infection is not available
Symptomatic HIV-antibody positive infant age < 18 mos with two or more of the following:
Oral candidiasis/thrush Severe pneumonia Severe wasting/malnutrition Severe sepsisSevere immunosuppression should be suspected and ARV
treatment is indicated CD4 values where available should be used to guide decision
making CD4 below 24% requires urgent ARV treatment Other factors that support the diagnosis of clinical stage 4 HIV
infection in an HIV seropositive infant are recent maternal death or advanced HIV disease in mother.
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Module 7: Paediatric HIV, KMA
Immunological Staging Differences in CD4 counts between
adults and children
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Module 7: Paediatric HIV, KMA
Immunological Staging Using Absolute CD4 count
Immune category < 12 monthsCD4 counts
1-5 yearsCD4 counts
6-12 yearsCD4 counts
1: Not immunosuppressed
> 1500 > 1000 > 500
2: Moderately immunosuppressed
750-1,499 500-999 200-499
3: Severely immunosuppressed
< 750 < 500 < 200
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Module 7: Paediatric HIV, KMA
Immunological Staging Using CD4 percentage
Immune category < 12 monthsCD4 %
1-5 yearsCD4 %
6-12 yearsCD4 %
1: Not immunosuppressed
> 25% > 25% > 25%
2: Moderately immunosuppressed
15-24% 15-24% 15-24%
3: Severely immunosuppressed
< 15% < 15% < 15%
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Module 7: Paediatric HIV, KMA
CDC Immunological staging
Immune category
< 12 monthsCD4 countsCD4 percentage
1-5 yearsCD4 countsCD4 percentage
6-12 yearsCD4 countsCD4 percentage
1: Not immunosuppressed
> 1500> 25%
> 1000> 25%
> 500> 25%
2: Moderately immunosuppressed
750-1,49915-24%
500-99915-24%
200-49915-24%
3: Severely immunosuppressed
< 750< 15%
< 500< 15%
< 200< 15%
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Module 7: Paediatric HIV, KMA
Total Lymphocyte Count Where cannot perform CD4 assays,
TLC provides a rough guide to level of immunosuppression.
This is only useful for baseline evaluation for immunosuppression.
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Module 7: Paediatric HIV, KMA
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Module 7: Paediatric HIV, KMA
Relationship between CD4 and Lymphocyte count (TLC)
Age CD4 Lymphocyte count/mm3
(Lymph count/litre)
< 18 mo < 20 % < 3400/mm3
(< 3.4 x 109/l)
18mo-5yr
< 15 % < 2300/mm3
(< 2.3 x 109/l)
6 yrs or more
< 15% or CD4 count < 200
< 1200/mm3
(< 1.2 x 109/l)
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Module 7: Paediatric HIV, KMA
Computing CD4%
CD4% = Absolute CD4 count per mm3 x 100
Total lymphocyte count per mm3
OR = Absolute CD4 count per litre x 100
Total lymphocyte count per litre
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Module 7: Paediatric HIV, KMA
Computing Total Lymphocyte Count
TLC = Lymphocyte percentage per litre x 100
White cell count per litre
TLC = Lymphocyte percentage per mm3 x 100
White cell count per mm3
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Module 7: Paediatric HIV, KMA
HIV – Related Conditions:Prevention and Treatment
Unit 4Management of HIV infected
Children
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Module 7: Paediatric HIV, KMA
Vaccination concerns in child with HIVBroad concerns include, is the child able: To mount an effective immune response to the
vaccine? To sustain their immune response as CD4
declines? Do they require re-vaccination after CD4 is
restored following successful antiretroviral therapy?
Safety of live vaccines - can live vaccines result in severe vaccine-associated disease in immunocompromised individuals?
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Module 7: Paediatric HIV, KMA
World Health Organization/UNICEF recommendations
For the Immunization of HIV-infected children and women
of childbearing age
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Module 7: Paediatric HIV, KMA
Vaccine Asymptomatic HIV
Symptomatic HIV
Optimal timing of immunization
BCG yes no birth
DPT yes yes 6,10,14 wks
OPV* Yes Yes 0, 6,10,14 wks
Measles Yes Yes 6 and 9 months
Hepatitis B
Yes Yes As for uninfected children
Yellow fever
Yes No**
Tetanus toxoid
Yes Yes 5 doses***
* IPV an alternative for children with symptomatic HIV** Pending further studies*** 5 doses TT for women of child-bearing age
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Module 7: Paediatric HIV, KMA
HIV-related Diseases
Infections that complicate HIV disease in children include:
Infections that are commonly seen even in HIV uninfected children
Opportunistic infections rare in HIV negative children more common with advancing immune
compromise.
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Module 7: Paediatric HIV, KMA
HIV-related Diseases (cont) Other clinical problems not
commonly seen in other children Lymphoid interstitial pneumonitis Malignancies HIV encephalopathy
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Module 7: Paediatric HIV, KMA
Pneumocystis Pneumonia Caused by a fungus, Pneumocystis jiroveci*, that
is commonly found in the environment Commoner under the age of 1 year and in
severely immunosuppressed children Clinical presentation:
Usually less than 1 year Tachypnoea Dyspnoea Low grade fever or afebrile Cough Hypoxemia (paO2 < 90%) Clear chest or fine crepitations Poor response to standard antibiotics
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Module 7: Paediatric HIV, KMA
Investigations
Chest X-ray: hyperinflation, diffuse infiltrates or may be normal
Sputum induction or nasopharyngeal aspirate, stained with Silver or Immunofluorescent stain
Bronchoalveolar lavage washing stained as above
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Module 7: Paediatric HIV, KMA
PCP Treatment
Cotrimoxazole I.V (or oral if IV not available) Trimethoprim (TMP): 4 mg/kg/dose qid Sulphamethoxazole (SMX): 20mg/kg/dose
qidOR
IV Pentamidine 4mg/kg/day ODDuration of treatment: 3 weeks
Add prednisone 2mg/kg for 7-14 days in severely ill children (taper off)
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Module 7: Paediatric HIV, KMA
Prevention of PCP PCP prevented by cotrimoxazole Co-trimoxazole prophylaxis
All children born to HIV infected women should receive CTZ prophylaxis from age of 6 weeks till HIV is ruled out.
Those confirmed to be HIV infected should continue CTZ prophylaxis indefinitely.
Dose 25mg SMX / 5mg TMP per kg o.d. (30mg cotrimoxazole/kg o.d.)
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Module 7: Paediatric HIV, KMA
Candidiasis Oral candidiasis a frequent OI May extend to oesophagus and
disseminate when CD4 severely depressed
Oesophageal candidiasis assoc with difficulty in swallowing/dysphagia
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Module 7: Paediatric HIV, KMA
Treatment of CandidiasisOral thrush: Clotrimazole mouth paint 10-20 drops p.o
qid 7 days (after feeds) or until thrush clears.
Or clotrimazole 10 mg troches (older children only)
Or: 0.25%-0.5% gentian violet solution 2% miconazole gel, 2.5 ml (young child) or
5 ml (older child) two times a day
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Module 7: Paediatric HIV, KMA
Treatment of Candidiasis
Oesophageal candidiasis: Oral ketoconazole , 3-6mg/kg/day for
7 days OR Oral fluconazole 3-6 mg/kg/day for 2-
3 weeks or until resolution of symptoms.
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Module 7: Paediatric HIV, KMA
Antiretroviral Therapy in Children
Unit 5Management of HIV infected
Children
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Module 7: Paediatric HIV, KMA
Antiretroviral Therapy
Will cover the following: Indications for ART initiation National ART Regimens Monitoring Indications for change or withdrawal of
ART National second line regimens ART and tuberculosis
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Module 7: Paediatric HIV, KMA
Criteria for ART Initiation
There are two broad criteria to consider prior to ART initiation
Medical criteria
Psychosocial criteria
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Module 7: Paediatric HIV, KMA
Criteria for ART InitiationMedical criteria WHO stage 3 or 4 disease (irrespective of CD4 counts or
%). Low CD4 count or percentage as follows (irrespective of
WHO stage): Child < 18 months – CD4 < 25% or absolute CD4
count < 1500 Child 18 months to 5 years – CD4 < 15% or absolute
CD4 count < 500 Child older than 5 years – CD4 < 15% or absolute
CD4 count < 200 Recurrent hospitalizations (> 2 admissions in previous
year) for HIV-related disease, or prolonged hospitalization (> 4 weeks) in previous year.
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Module 7: Paediatric HIV, KMA
Criteria For ART InitiationPsychosocial criteria An identifiable parent or guardian who is able
to understand the regimen, and consistently administer the child’s medication.
Adolescent – disclosure of HIV diagnosis before ART initiation recommended where possible
Ability to regularly attend the HIV clinic appointments.
Sustainable long-term access to antiretroviral drugs (either through programs providing ART, or financially able to purchase ARV drugs).
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Module 7: Paediatric HIV, KMA
Preparing a Child for ART
Prior to initiating ART, the following preparations should take place
Medical Preparation
Counseling Preparation
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Module 7: Paediatric HIV, KMA
Preparing a Child for ART (2)Medical Preparation Baseline tests to check haematological,
liver and kidney function: Full blood count (resources limited, do Hb) Liver function tests (resources limited, do
alanine transaminase or ALT) Renal function tests (resources limited, do
serum creatinine) Do baseline CD4 if possible Do baseline viral load (RNA PCR – this is
optional if resources limited)
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Module 7: Paediatric HIV, KMA
Preparing a Child for ART (3)Medical Preparation (continued) Baseline clinical assessment including
weight, height, surface area. If current TB suspected, investigate for
TB (If TB confirmed, consider delaying ART initiation)
Initiate co-trimoxazole prophylaxis (as in module 5)
Treat any inter-current illnesses
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Module 7: Paediatric HIV, KMA
Prior to starting ARV in childrenStart in haste, repent at leisure!!Starting ART is never an emergencyTake time to counsel, prepare, educate the
familyCounsel the caregiver on: Cost – drugs, monitoring tests, food security Adherence to therapy – strict time scheduling Support, support, support. Child can’t do it
alone. Older child – disclosure to childDo careful social assessment of family situation
prior to starting therapy.
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Module 7: Paediatric HIV, KMA
Goals of ARV Therapy Maximal and durable
suppression of HIV replication. Restoration and preservation
of immune function. Reduce HIV related Morbidity
& Mortality. Improve quality of life.
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Module 7: Paediatric HIV, KMA
Special Considerations for Children and ARVsChoose drugs that: Do not have to be timed around meals Have acceptable taste Suspensions/syrups are stable at room
temperature if patient does not own a refrigerator.
Children older than 6 years may take tablet and capsule formulations
Some capsule formulations may be opened and capsule content mixed with food or drink.
Some chewable tablets may be crushed and mixed with food or drink.
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Module 7: Paediatric HIV, KMA
Types of Antiretroviral Drugs
1. Nucleoside reverse transcriptase inhibitors (NRTI)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTI)
3. Protease inhibitors (PI)
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Module 7: Paediatric HIV, KMA
Kenya national recommended 1st line ART in childrenAlways give three drugs (triple therapy). National first line regimen – use 2 nucs and 1 non-nuc
Age < 3 years Zidovudine (ZDV) + Lamivudine (3TC) + Nevirapine
(NVP)
Age > 3 years ZDV + 3TC + Efavirenz (EFV) or NVP.
These can be taken with or without food, taste is acceptable, and all are stable at room temperature.
If child very anaemic, ZDV may be substituted by stavudine (D4T)
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Module 7: Paediatric HIV, KMA
First line regimen in NVP-exposed child
Child exposed to single dose nevirapine for PMCT may have NVP resistant virus. Avoid non-nucs in their 1st line regimen
AZT (or d4T) + 3TC + Kaletra
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Module 7: Paediatric HIV, KMA
ART and TuberculosisRifampicin interacts with nevirapine and most
protease inhibitorsIf possible, complete anti-TB therapy before ART
initiation. If child too sick to wait, and anti-TB therapy must
be given with ART use the following regimen: Child < 3 yr – Replace NVP with abacavir. After
completing anti-TB therapy revert to NVP Child > 3 yr – Two NRTIs with efavirenz
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Module 7: Paediatric HIV, KMA
Dosages of ARV drugs Many are calculated using surface area S.A = sq root of ([wt x ht] / 3600) Others calculated using weight for age Failure to compute dosage correctly
leads to under- or over-dosing Suboptimal dose – resistance Overdose – toxicity
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Module 7: Paediatric HIV, KMA
Clinical Monitoring Clinical response – anthropometry, physical
exam at every visit Symptoms improving, static, deteriorating? Growth (weight, height) General well-being
Clinical signs of specific adverse effects (depend on class of drugs)
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Module 7: Paediatric HIV, KMA
Laboratory Monitoring Response to therapy
CD4 every 6 months (expect rise within 6 months)
Viral load at baseline, month 3 then every 6 months if affordable (aim at 5-fold drop by 8-12 weeks)
Adverse effects FBC, SGPT/ALT at baseline, month 1, then 3
monthly or as appropriate Others (lipids, glucose etc) as appropriate
for toxicity or inter-current illnesses
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Module 7: Paediatric HIV, KMA
When to change or stop ART
1. Toxicity – replace only the offending drug
2. Treatment failure – replace all 3 drugs
3. Poor adherence – if cannot rectify, withdraw ART
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Module 7: Paediatric HIV, KMA
When to change ART
Toxicity – replace offending agent only with equivalent drug
Hb < 7gm/dl Platelets < 49,000 Neutrophils < 250 Bilirubin 3-7x upper normal SGPT 10x upper normal Amylase, lipase: 2-3x upper normal Neuropathy, severe dermatitis Lipoatrophy, pancreatitis
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Module 7: Paediatric HIV, KMA
Indications for change of therapy – treatment failure
FIRST CHECK ADHERENCE!!
Clinical indications Progressive neurodevelopmental
deterioration Growth failure Disease progression – move from
one stage to next
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Module 7: Paediatric HIV, KMA
Indications for change of therapy – treatment failure
Immunological indications For kids with CD4 below 15%,
decline of ≥ 5 percentile points Rapid decline in absolute CD4
count (loss of > 1/3 of CD4 cells in < 6 months)
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Module 7: Paediatric HIV, KMA
Indications for change of therapy – treatment failureVirological indications
Persistent increase in viral load (confirmed by 2 tests)
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Module 7: Paediatric HIV, KMA
Second line therapy – factors to consider Change ALL 3 DRUGS. Include a Protease inhibitor. Replace the NRTIs with two new NRTIs Replace the NNRTI with a PI IF initial problem was adherence to
therapy, must address this first. If can’t best to just withdraw therapy altogether
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Module 7: Paediatric HIV, KMA
Kenya national recommended 2nd line ART in children
First line ZDV/3TC/NVP or
EFV
d4T/3TC/NVP or EFV
ZDV/3TC/Kaletra
Second line ddI/ABC/LPV/r or
ddI/ABC/NFV
ddI/ABC/LPV/r or NFV
ddI/ABC/PI/ritonavir
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Module 7: Paediatric HIV, KMA
When To Stop/withdraw ART.
ART should be withdrawn in the following situations:
Severe adverse effects (lactic acidosis)
Intolerability, inability to take drugs. Poor adherence Interruption of drug supply Patients wish.
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Module 7: Paediatric HIV, KMA
Adherence Issues to Consider
Children depend upon adults to administer drugs
Adherence may be affected by stage of development (spitting, vomiting, running away)
Providers need to teach families techniques of giving medicine to young children Use of syringe for measurement and
administration Crushing of meds Mixing in fruit juice, other foods Opening of capsules Repeat dose if vomited