October 14 Nursing Priorities: An Important Role in Pediatric HIV Disease

1. October 14 Nursing Priorities: An Important Role in Pediatric HIV Disease Suzanne Willard, PhD, CRNP, FAAN

2. Nursing Prioritiesan Important Role in Pediatric HIV Disease

3. Learning Objectives • Understand the role of nursing in the care of HIV-infected infants and children • Demonstrate nursing implications in providing care to children and their families.

4. Goals for Care of HIV-Infected Infants & Children • Model of care • Family-centered • HIV primary care • Multidisciplinary team • Maximize health & prevent disease progression • Prevent early death • Prevent OI • Maximize growth and development • Reduce hospitalization rate • Reduce frequency of intercurrent illnesses

5. HIV Disease in Children • Rapid disease course compared with adults • Bimodal distribution of disease manifestations • >30% with rapid disease progression • Majority with symptoms by 12 months • 50% mortality by 24 months • <5% long term nonprogressors

7. Diagnosis • Get sick • Get tested

8. Testing

9. Who to test • All children known to be exposed • All children in the wards • All children whose mother’s status is unknown • Malnourished • Children presenting for outpatient clinical consultation • Routine testing

10. Common Clinical Manifestations • Infancy and early childhood - rapid progression • poor growth/failure-to-thrive/weight loss • pneumonia (PCP & TB) • encephalopathy • recurrent, severe infections • diarrhea • Older children • poor growth • recurrent infections • lymphoid interstitial pneumonia (LIP) • dermatitis • Clinical manifestations vary considerably

11. HIV during infancy = primary infection Acquisition of HIV can occur • in utero • Intrapartum • postnatally through breast feeding Maturing/developing immune system of the newborn

12. Multiple factors influence rate of disease progression Maternal advanced disease Maternal vital status Timing of transmission (peripartum vs. late) Genetic susceptibility Virus characteristics

13. How Will We Meet the Goals for Care ? • Maximize health & prevent disease progression • By providing: • HIV Primary Care • Frequent Monitoring • OI prophylaxis • Nutritional Assessment & Management • Management of Disease Manifestations • Psychosocial Support • ARV Treatment • Family-centered care • Multidisciplinary Team Approach

15. Baseline History • Birth history including maternal history, gestational age, birth parameters and route and place of delivery • Medical History – what has happened until now? • Childhood illness and immunizations • Family History • Psychosocial history of the patient and the family • Nutritional history

16. Why conduct a history at each visit? • Develop a clinical profile of the child • Identify changes in health status since last visit • Identify changes in home setting that may affect child’s health • Review what has changed, what has improved or gotten worse

17. Attention to Onset and course of the problem New problems Problems associated with fever Problems that have not responded to treatment Growth and Development

18. Weight-for-Age, Height-for-AgeBoy & Girl Growth Charts

19. Why Use Growth Curves? • Easy and systematic way to follow changes in growth over time for an individual child • Weight, height and head circumference should be plotted at regular intervals • Monthly for HIV infected infants • Quarterly for older HIV-infected children

20. Weight for Height The child is in the 50th percentile of weight for age The child weighs 7.2 kg She is six months old

21. Development

22. Developmental Assessment At every visit • Ask about the infant’s development • Simple questions should focus on four critical developmental domains; cognitive, motor, language, and social. • This can be done through observation during the physical exam or asking the parent • Delayed acquisition of developmental milestones or loss of previously acquired skills can be the first sign of HIV encephalopathy.

23. Nutritional Evaluation At every visit: • What are they eating and how? • Weigh, measure and examine child • Use growth curves to monitor growth pattern • Any child who is not thriving needs extensive nutritional history

24. Physical Examination At every visit • Perform careful physical examination • Initial exam should be comprehensive including examination of all organ systems • Identify any HIV related physical findings; thrush, lymphadenopathy, organomegaly, dermatitis,encepatholpathy etc • Subsequent exams can be guided by findings on the symptom/sign checklist

25. Which Laboratory Tests Need To Be Done? • Complete Blood Count • CD4 number and percent • When an infant is determined to be HIV-infected • Upon enrollment for older children • Every six months thereafter

26. Treatment • It Works! • New WHO Guidelines • Stage III and IV – TREAT! • Under 24 months – TREAT! • 2 to 5 years – cd4 <750 – TREAT! • Older than 5 - < 350 – TREAT!

27. WHO Clinical Staging System • Stage I • Asymptomatic, PGL • Stage II • HSM, Papular Pruritic Eruptions, Extensive HPV, Extensive Molluscum, Fungal Nail Infections, Recurrent Oral Ulcers, Parotid Enlargement, Zoster, Recurrent or Chronic URTIs • Stage III • Moderate unexplained/unresponsive malnutrition, unexplained persistent diarrhea or fever, Oral Candidiasis, Pulmonary TB, Unexplained Anemia/Neutropenia/ Thrombocytopenia, Severe Recurrent Bacterial Pneumonia • Stage IV • Severe wasting, PCP, Extrapulmonary TB, severe bacterial infections (Pyomyositis, Empyema, Osteomyelitis, Meningitis) KS, CNS toxoplasmosis, HIV Encephalopathy, Cryptosporidiosis, Isosporiasis, cerebral or B-cell Lymphoma, Candida of esophagus, trachea, bronchi or lung

28. Sara • Sara is 7 years old. She’s been hospitalized twice, once with bad pneumonia and once with shingles. She has had diarrhea off and on for 4 months. • She is less than the 5th percentile for weight, but no old data is available for comparison. On examination she is thin and small with no other abnormalities noted. • Should you consider her for being at risk for HIV? • What is her staging?

29. WHO Clinical Staging System for Sara • Stage I • Asymptomatic, PGL • Stage II • HSM, Papular Pruritic Eruptions, Extensive HPV, Extensive Molluscum, Fungal Nail Infections, Recurrent Oral Ulcers, Parotid Enlargement, Zoster, Recurrent or Chronic URTIs • Stage III • Moderate unexplained/unresponsive malnutrition, unexplained persistent diarrhea or fever, Oral Candidiasis, Pulmonary TB, Unexplained Anemia/Neutropenia/ Thrombocytopenia, Severe Recurrent Bacterial Pneumonia • Stage IV • Severe wasting, PCP, Extrapulmonary TB, severe bacterial infections (Pyomyositis, Empyema, Osteomyelitis, Meningitis) KS, CNS toxoplasmosis, HIV Encephalopathy, Cryptosporidiosis, Isosporiasis, cerebral or B-cell Lymphoma, Candida of esophagus, trachea, bronchi or lung

30. WHO Staging for Sara • New WHO staging • Stage III (Advanced)

31. Determining whether a children is eligible for ARV Treatment should be done at every visit, at every encounter and you should have a high level of suspicion for any ill child.

32. Can you or should you prescribe as a nurse? YES You Can! with training with support with confidence If it is within the jurisdiction of the country where you are practicing.

33. Assess adherence • Children often hide medications from their caretakers, does the caretaker watch the swallowing • Consider same regimens of caregiver if possible • Talk to the child

34. Adherence Issues specific to Children • The Medication itself • The Child • The Caretaker • It is Most Important to • Talk to the child

35. Other issues affecting children • HIV infection is a multi generational disese • Parent may lack parenting skills to administer medications • Parent may be too ill or has delegated to another caretaker • Chaotic home environment • Parents may be dealing with own feelings of guilt • Lack of social support systems to help cope

36. Before you start • Teach pill swallowing – over 4 years • Stress need for attending routine visits even when feeling good • Educate Family • Side effects, when to call for help, who they should call

37. Anticipatory guidance • What to do if the child vomits • Has diarrhea • If dose is late • If routine changes because of travelling

38. Adherence assessment • Do not assume that the family understands • Use job aids • Interview child and the caretaker seperatly • What are the reasons that you typically forget? i.e. taste, felt sick, didn’t want to take • Share an instance in which you may have trouble remembering to take the medication

41. Patient Education • Make sure they understand • Don’t assume they all ready know. • Ask questions – get them to participate • Utilize peer educators • When teaching parents how to give medications to their children – watch them give a dose.

42. Linkages • Between PMTCT care and treatment • Make sure that getting the services is convenient to the pregnant woman • Between the clinic and the home

45. Next session: October 21, Malaria Listserv: itechdistlearning@uw.edu Email: DLinfo@uw.edu

46. Next session: Oct 21 Malaria Paula Brentlinger, MD, MPH