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Women, children, Family care

Case Mrs M and her children . Jeannie, 3 years old. Condition deteriorated in the last few monthsRecurrent pneumonia, bouts of diarrhoea and weight lossTested for HIV: rapid test positive CD4 T-cell count 285/mm3 (11 %). . Jeannie's brother Bruno, 1 year old. Skinny infantOral candidiasis re

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Women, children, Family care

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    1. Women, children, & Family care Margaret Siwale, MD , Pediatrician Lusaka Trust Hospital, Zambia Sibyl Geelen, MD,PhD , Ped Infect Dis Specialist CCPD/PharmAccess Foundation & UMCU, The Netherlands

    2. Case Mrs M and her children

    3. Jeannie, 3 years old Condition deteriorated in the last few months Recurrent pneumonia, bouts of diarrhoea and weight loss Tested for HIV: rapid test positive CD4 T-cell count 285/mm3 (11 %).

    4. Jeannie’s brother Bruno, 1 year old Skinny infant Oral candidiasis recently Persistent diarrhoea Not tested for HIV yet Social situation Father died last year Mother sells vegetables at the market During daytime, kids are taken care of by grandmother

    5. How would you diagnose HIV infection in Bruno in your setting? How do you decide whether Jeannie and/or Bruno need antiretroviral therapy?

    6. Staging of HIV/AIDS in children and infants Two different classification systems WHO CDC

    8. Both clinical and immunological classification have been modified Clinical staging ? 4 stages (previously 3) Immunologic staging ? 4 stages (previously 3)

    9. WHO pediatric clinical staging

    10. WHO pediatric clinical staging (cont’d)

    11. WHO pediatric clinical staging (cont’d)

    12. WHO pediatric clinical staging (cont’d)

    13. Revised WHO pediatric immune classification – CD4 count and percentage of total lymphocytes

    14. In using CD4+ count or % for HAART decision use age-appropriate levels ! Remember

    15. Case cont’d Jeannie aged 3 years WHO clinical stage 3 CD4 285/mm3 (11%) Strategy ?

    16. WHO Criteria to start HAART in children Revised draft version Oct 2005 WHO stage 4 WHO stage 3 ? Treat irrespective of CD4-T cell % or count ? HAART indicated for majority of children However, in children >18 months with - pulmonary TB, - lymphocytic interstitial pneumonia (LIP), - oral hairy leukoplakia, - or thrombocytopenia, HAART may be deferred if CD4 values are above the threshold values to initiate HAART

    17. WHO Criteria to start HAART in children Revised draft version Oct 2005 WHO stage 2 and 1 ? Use CD4-T cell % or count to guide decisions on ART initiation For those settings where CD4-T cell count is not available: WHO also provides values on total lymphocyte counts

    18. Case cont’d Bruno aged 1 year HIV rapid test + No HIV-PCR testing available CD4 count 350/mm3 (15%) Strategy ? what would you do if you do not have access to CD4 determination ?

    19. A presumptive diagnosis of severe HIV disease in infants and children aged under 18 months in situations where virological confirmation of HIV infection is not available, should be made if Infant is confirmed HIV-antibody positive Aged under 18 months and Symptomatic with two or more of the following clinical signs - oral thrush (candidiasis) - severe pneumonia - severe wasting/malnutrition - severe sepsis Other factors that support the diagnosis of severe HIV disease in an HIV seropositive infant include - recent HIV related maternal death or - advanced HIV disease in the mother - CD4-T cells < 25% Confirmation of the diagnosis of HIV infection should be sought as soon as possible

    20.

    21. Poor prognosis in HIV-1 infected African infants n=3,468 children pooled analysis of 7 clinical trials in sub-Saharan Africa

    22. Steps to successful HAART in children

    23. Steps to successful HAART in children Child HIV diagnosis confirmed? Comprehensive clinical and laboratory assessment WHO or CDC classification Is the child eligible for antiretroviral therapy according to the WHO or CDC criteria?

    24. Steps to successful HAART in children Mother/caregiver Has the mother/caregiver received information on ARV’s, expected outcomes, potential side effects? Does the mother appreciate the need for intensive monitoring and follow-up? Has the importance of adherence been discussed? Have barriers to adherence been discussed and resolved as far as possible? (if needed with support of community support groups)

    25. Which obstacles do you encounter most frequently?

    26. Assess patient & family readiness Potential barriers….. Has the mother disclosed HIV status to anyone? Do the other people in the household know about the child’s diagnosis? Is there support in the household/family? Is the living situation stable? Other

    27. Assess patient & family readiness Who will give the medications to the child? Does this person know when/how much to give? Does the caregiver recognize the need for the child to take ARV for life, even if they have no symptoms or feel better? Does the caregiver have an understanding of the importance of poor adherence and the consequences Does the caregiver have a plan for when to give ARV and how not to miss doses? Has the child tasted the medications? How does the child’s developmental level influence ability to take medications? Has the health provider observed the administration of medication?

    29. Remember

    30. Remember…… Children are dependent upon adults to administer or supervise administration of their medications Children can exert considerable influence on adherence dependent upon developmental stage spitting, vomiting, refusing, running away… Healthcare providers need to teach families techniques to give medication to young children

    31. Which regimen would you prescribe for Jeannie and/or Bruno in your setting ?

    32. Zidovudine or Stavudine plus Lamivudine plus Nevirapine or Efavirenz (children > 3 yrs) Most frequently used first line HAART

    34. Response to HAART in children Usually good clinical response Usually good recovery of immune system, better than in adults Variable virologic response Continued support of the family is essential (multidisciplinary team)

    35. 660,000 children are in need of treatment 40% less than 18 months of age Only 20,000-25,000 receive therapy Why aren’t more children receiving ARVs ?

    36. Obstacles Availability of pediatric medication costs & formulations Diagnosis in infants < 18 months tests expensive and complicated Expertise of health care workers Social and political issues

    37. Pediatric medication

    38. Problems with liquids in resource limited settings Cost Price 3-10 times higher, not affordable in many settings In practice: half as many children as adults treated for the same budget Practical Not all antiretrovirals exist in liquid form Liquids can be cumbersome ? difficult to store, handle, transport Large volumes, poor taste Some liquids have to be kept cold

    39. Pills/Tablets No “ fixed dose tablets” for babies and children Adult tabs are broken in ˝ and ź (or even smaller parts) Probably okay for older children Risk of under-or overdosing in infants

    40. “Pedimmune” Pediatric version of adult Triomune (d4T,3TC,NVP) “Junior” and “Baby” On the market in 2006 ?

    41. Expertise of healthcare workers

    42.

    43. Day care, Lusaka

    44. Social and Political obstacles

    45. Both policy makers and caregivers are often unconvinced that antiretroviral therapy works in children! Stigma and secrecy “The disease of shame”

    46. Case cont’d Both children start HAART How would you organize follow-up?

    47. Remember Always assess knowledge Always calculate and recalculate drug dosages based on weight, size and/or age Constantly assess adherence Anticipate non-adherence during crisis periods for the patients Sustain supportive activities Support family adherence efforts at every step Don’t forget to share and celebrate treatment successes

    48. Mrs M, mother of the family

    49. Mrs M, 26 years old Suffered from recurrent thrush Pneumonia twice in the previous 2 years Knows that she is HIV positive since 1 year Now 2 months pregnant Worried that the baby will be infected Hasn’t informed her new partner about the HIV infection

    50. Mrs M Which issues do you consider to be important to discuss with Mrs M at this stage ?

    51. Mrs M Education and counselling Medical ? Staging Social ? Disclosure

    52. Mrs M has WHO stage 2 CD4 150/mm3 Strategy ? Mrs M needs HAART for her own health

    53. Preferably start HAART at 14 weeks (after first trimester) BUT: first check readiness Continue HAART after birth: yes Prophylaxis for the baby: yes (to follow)

    54. Suppose Mrs M has WHO stage 2 CD4 420/mm3 Strategy ? HAART not yet indicated for her own health What would you recommend for PMTCT ?

    55. What does WHO currently recommend ? Existing and upcoming guidelines will not recommend HAART in this situation but They will also not definitely recommend against it

    56. WHO advice: If capacity to deliver full range of ARVs Mother Pregnancy: start AZT at wk 28 or as soon as feasible thereafter Intrapartum: continue AZT + single dose NVP + consider 3TC Postpartum: continue AZT + 3TC for 7 days Infant single dose NVP + AZT 7 days

    57. WHO advice: If capacity to deliver only minimum range of ARVs for PMTCT (e.g no AZT available) Mother Pregnancy: nothing Intrapartum: single dose NVP Postpartum: nothing Infant single dose NVP

    58. Thus Choice of PMTCT regimen (HAART or other PMTCT regimen) will depend on local circumstances and national guidelines

    59. After Mrs M has given birth: what infant-feeding practice would you recommend?

    60. Infant feeding Increases risk of transmission of HIV by 10-20% Lack of breast feeding can expose children to risks of malnutrition or infections In the village, not breast feeding brings stigma Striking a balance is quite complicated Good and effective counselling essential Need to consider the risk and benefits according to the situation

    61. Are there options to prevent postpartum transmission if substitute feeding is not possible ? Under investigation Effect of continued maternal HAART while breastfeeding (Bultereys JID 2005;192) Prolonged ARV prophylaxis in the infant while being breastfed (SIMBA study, not published yet)

    62. In summary: the challenges Advocacy- keep children on the agenda Improve knowledge and expertise on pediatric ART Encourage uptake of children in programmes Recognize the special needs of children Assert pressure for development of affordable pediatric formulations Maximize efforts to reduce mother-to-child transmission

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