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Ppediatric hiv june06

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D
David Ngogoyo
Health & Medicine
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Management of HIV infected Children KMA Curriculum Module 7 June 2006
Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Epidemiology and HIV transmission in Children Unit 1 Management of HIV infected Children
Epidemiology - Kenya ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Modes of HIV transmission to Children ,[object Object],[object Object],[object Object],[object Object]
Mother to Child HIV Transmission 30% babies born to HIV+ women become infected through MTCT 5% intrauterine 10-20% during delivery 10-20% via breastfeeding
Modes of HIV transmission to Children ,[object Object],[object Object],[object Object],[object Object],[object Object]
Natural history of HIV in Children Unit 2: Management of HIV infected Children
Natural history – patterns of disease progression in African children ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Natural history – patterns of disease progression in African children ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Natural History – Immunological changes ,[object Object],[object Object],[object Object],[object Object],[object Object]
Natural History – Immunological changes
Natural History – Immunological changes
Natural History – Viral load patterns in children ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical signs & conditions suggestive of HIV infection in a child ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical signs & conditions suggestive of HIV infection in a child ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical signs & conditions suggestive of HIV infection in a child ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis and Staging of HIV in Children Unit 3 Management of HIV infected Children
DIAGNOSIS OF PEDIATRIC HIV
Clinical Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical suspicion of pediatric HIV ,[object Object]
Laboratory Diagnosis Child < 18 months ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Laboratory Diagnosis Child < 18 months ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis – combining lab and clinical criteria ,[object Object],[object Object]
HIV Diagnosis before age 18 mth without virologic test ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis ,[object Object],[object Object],[object Object]
DIAGNOSIS - summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
STAGING PEDIATRIC HIV
Clinical Staging ,[object Object],[object Object],[object Object],[object Object],[object Object]
Disease Staging ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Staging Severe (AIDS) 4 C Moderate 3 B Mild 2 A Asymptomatic 1 N Stage WHO CDC
WHO clinical staging ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO Clinical Staging – stage 1 ,[object Object],[object Object],[object Object],[object Object]
WHO Clinical Staging - stage 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO Clinical Stage 2 ,[object Object],[object Object],[object Object],[object Object]
WHO Clinical Staging – Stage 3 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO Clinical Staging – Stage 3 (continued) ,[object Object],[object Object],[object Object],[object Object],[object Object]
WHO stage 4 – all ages ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO stage 4 – all ages (continued) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO – Stage 4: Child < 18 mths - when PCR testing not available ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Immunological Staging ,[object Object]
Immunological Staging Using Absolute CD4 count < 200 < 500 < 750 3: Severely immunosuppressed 200-499 500-999 750-1,499 2: Moderately immunosuppressed > 500 > 1000 > 1500 1: Not immunosuppressed 6-12 years CD4 counts 1-5 years CD4 counts < 12 months CD4 counts Immune category
Immunological Staging Using CD4 percentage < 15% < 15% < 15% 3: Severely immunosuppressed 15-24% 15-24% 15-24% 2: Moderately immunosuppressed > 25% > 25% > 25% 1: Not immunosuppressed 6-12 years CD4 % 1-5 years CD4 % < 12 months CD4 % Immune category
CDC Immunological staging < 200 < 15% < 500 < 15% < 750 < 15% 3: Severely immunosuppressed 200-499 15-24% 500-999 15-24% 750-1,499 15-24% 2: Moderately immunosuppressed > 500 > 25% > 1000 > 25% > 1500 > 25% 1: Not immunosuppressed 6-12 years CD4 counts CD4 percentage 1-5 years CD4 counts CD4 percentage < 12 months CD4 counts CD4 percentage Immune category
Total Lymphocyte Count ,[object Object],[object Object]
 
Relationship between CD4 and Lymphocyte count (TLC) < 2300/mm 3 (< 2.3 x 10 9 /l) < 15 % 18mo-5yr < 1200/mm 3 (< 1.2 x 10 9 /l) < 15% or CD4 count < 200 6 yrs or more < 3400/mm 3 (< 3.4 x 10 9 /l) < 20 % < 18 mo Lymphocyte count/mm 3 (Lymph count/litre) CD4 Age
Computing CD4% ,[object Object],[object Object],[object Object],[object Object]
Computing Total Lymphocyte Count ,[object Object],[object Object],[object Object],[object Object]
HIV – Related Conditions: Prevention and Treatment Unit 4 Management of HIV infected Children
Vaccination concerns in child with HIV ,[object Object],[object Object],[object Object],[object Object],[object Object]
World Health Organization/UNICEF recommendations For the Immunization of HIV-infected children and women of childbearing age
* IPV an alternative for children with symptomatic HIV ** Pending further studies *** 5 doses TT for women of child-bearing age 5 doses*** Yes Yes Tetanus toxoid No** Yes Yellow fever As for uninfected children Yes Yes Hepatitis B 6 and 9 months Yes Yes Measles 0, 6,10,14 wks Yes Yes OPV* 6,10,14 wks yes yes DPT birth no yes BCG Optimal timing of immunization Symptomatic HIV Asymptomatic HIV Vaccine
HIV-related Diseases ,[object Object],[object Object],[object Object],[object Object],[object Object]
HIV-related Diseases (cont) ,[object Object],[object Object],[object Object],[object Object]
Pneumocystis Pneumonia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Investigations ,[object Object],[object Object],[object Object]
PCP Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prevention of PCP ,[object Object],[object Object],[object Object],[object Object],[object Object]
Candidiasis ,[object Object],[object Object],[object Object]
Treatment of Candidiasis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment of Candidiasis ,[object Object],[object Object],[object Object]
Antiretroviral Therapy in Children Unit 5 Management of HIV infected Children
Antiretroviral Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Criteria for ART Initiation ,[object Object],[object Object],[object Object]
Criteria for ART Initiation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Criteria For ART Initiation ,[object Object],[object Object],[object Object],[object Object],[object Object]
Preparing a Child for ART ,[object Object],[object Object],[object Object]
Preparing a Child for ART (2) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Preparing a Child for ART (3) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Prior to starting ARV in children ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Goals of ARV Therapy ,[object Object],[object Object],[object Object],[object Object]
Special Considerations for Children and ARVs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Types of Antiretroviral Drugs ,[object Object],[object Object],[object Object]
Kenya national recommended 1st line ART in children ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
First line regimen in NVP-exposed child ,[object Object],[object Object]
ART and Tuberculosis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Dosages of ARV drugs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object]
Laboratory Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
When to change or stop ART ,[object Object],[object Object],[object Object]
When to change ART ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Indications for change of therapy – treatment failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
Indications for change of therapy – treatment failure ,[object Object],[object Object],[object Object]
Indications for change of therapy – treatment failure ,[object Object],[object Object]
Second line therapy – factors to consider ,[object Object],[object Object],[object Object],[object Object],[object Object]
Kenya national recommended 2 nd line ART in children ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
When To Stop/withdraw ART. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adherence Issues to Consider ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Ppediatric hiv june06

  • 1. Management of HIV infected Children KMA Curriculum Module 7 June 2006
  • 2.
  • 3. Epidemiology and HIV transmission in Children Unit 1 Management of HIV infected Children
  • 4.
  • 5.
  • 6. Mother to Child HIV Transmission 30% babies born to HIV+ women become infected through MTCT 5% intrauterine 10-20% during delivery 10-20% via breastfeeding
  • 7.
  • 8. Natural history of HIV in Children Unit 2: Management of HIV infected Children
  • 9.
  • 10.
  • 11.
  • 12. Natural History – Immunological changes
  • 13. Natural History – Immunological changes
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. Diagnosis and Staging of HIV in Children Unit 3 Management of HIV infected Children
  • 20.
  • 21.
  • 22.
  • 23.
  • 24.
  • 25.
  • 26.
  • 27.
  • 29.
  • 30.
  • 31. Clinical Staging Severe (AIDS) 4 C Moderate 3 B Mild 2 A Asymptomatic 1 N Stage WHO CDC
  • 32.
  • 33.
  • 34.
  • 35.
  • 36.
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.
  • 42. Immunological Staging Using Absolute CD4 count < 200 < 500 < 750 3: Severely immunosuppressed 200-499 500-999 750-1,499 2: Moderately immunosuppressed > 500 > 1000 > 1500 1: Not immunosuppressed 6-12 years CD4 counts 1-5 years CD4 counts < 12 months CD4 counts Immune category
  • 43. Immunological Staging Using CD4 percentage < 15% < 15% < 15% 3: Severely immunosuppressed 15-24% 15-24% 15-24% 2: Moderately immunosuppressed > 25% > 25% > 25% 1: Not immunosuppressed 6-12 years CD4 % 1-5 years CD4 % < 12 months CD4 % Immune category
  • 44. CDC Immunological staging < 200 < 15% < 500 < 15% < 750 < 15% 3: Severely immunosuppressed 200-499 15-24% 500-999 15-24% 750-1,499 15-24% 2: Moderately immunosuppressed > 500 > 25% > 1000 > 25% > 1500 > 25% 1: Not immunosuppressed 6-12 years CD4 counts CD4 percentage 1-5 years CD4 counts CD4 percentage < 12 months CD4 counts CD4 percentage Immune category
  • 45.
  • 46.  
  • 47. Relationship between CD4 and Lymphocyte count (TLC) < 2300/mm 3 (< 2.3 x 10 9 /l) < 15 % 18mo-5yr < 1200/mm 3 (< 1.2 x 10 9 /l) < 15% or CD4 count < 200 6 yrs or more < 3400/mm 3 (< 3.4 x 10 9 /l) < 20 % < 18 mo Lymphocyte count/mm 3 (Lymph count/litre) CD4 Age
  • 48.
  • 49.
  • 50. HIV – Related Conditions: Prevention and Treatment Unit 4 Management of HIV infected Children
  • 51.
  • 52. World Health Organization/UNICEF recommendations For the Immunization of HIV-infected children and women of childbearing age
  • 53. * IPV an alternative for children with symptomatic HIV ** Pending further studies *** 5 doses TT for women of child-bearing age 5 doses*** Yes Yes Tetanus toxoid No** Yes Yellow fever As for uninfected children Yes Yes Hepatitis B 6 and 9 months Yes Yes Measles 0, 6,10,14 wks Yes Yes OPV* 6,10,14 wks yes yes DPT birth no yes BCG Optimal timing of immunization Symptomatic HIV Asymptomatic HIV Vaccine
  • 54.
  • 55.
  • 56.
  • 57.
  • 58.
  • 59.
  • 60.
  • 61.
  • 62.
  • 63. Antiretroviral Therapy in Children Unit 5 Management of HIV infected Children
  • 64.
  • 65.
  • 66.
  • 67.
  • 68.
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
  • 74.
  • 75.
  • 76.
  • 77.
  • 78.
  • 79.
  • 80.
  • 81.
  • 82.
  • 83.
  • 84.
  • 85.
  • 86.
  • 87.
  • 88.
  • 89.

Editor's Notes

  1. If infant negative, repeat tests after 3-6 months. If infant still breastfeeding, wait until 3 months after cessation of breastfeeding to confirm final HIV status.
  2. AIDS Surveillance Case Definition (Severe HIV Disease) Case surveillance definition for reporting severe HIV disease only Not for diagnosis or management of individual patients Severe HIV Disease In the absence of CD4 count All clinical stage 3 and 4 disease Where CD4 available Stage 4 disease + any CD4 count CD4&lt;350
  3. P. Carinii has been renamed P. jiroveci but the eponym PCP is retained (Emerg Infect Dis 2002;8:891
  4. The first regimen must be selected with the aim of suppressing the virus replication to the maximum achievable levels in the shortest time possible. It needs also to have the quality of durability by not inducing resistance early . Its side effects must be tolerable to the patient so that the quality of life is improved.
  5. didanosine + abacavir + PI/ritonavir (ddI) (ABC) (LPV/r if NFV used)