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Caring for the HIV Exposed Child

Caring for the HIV Exposed Child. Dr. Anthony Edozien Assistant Professor of Medicine University of Maryland School of Medicine. Institute of Human Virology. 2. Defining Exposure. Exposure to the risk of infection Exposure to an HIV affected family.

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Caring for the HIV Exposed Child

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  1. Caring for the HIV Exposed Child Dr. Anthony Edozien Assistant Professor of Medicine University of Maryland School of Medicine. Institute of Human Virology

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  3. Defining Exposure • Exposure to the risk of infection • Exposure to an HIV affected family

  4. Defining Exposure: Exposure to the risk of HIV infection (Principle risk) <1% 2% 5% 13% Cumulative risk by birth = 20% 65% 15% Cumulative risk by 2 years = 35%

  5. Defining Exposure: Exposure to the HIV affected family • Orphan-hood—death of one or both parents • Malnutrition/under-nutrition—associated with rapid weaning of exposed infants • Diarrheal illness—associated with rapid weaning of exposed infants • Poverty—associated with ill parents unable to work

  6. Defining Exposure: Exposure to the HIV affected family Mortality at 15 months median follow-up among infected and uninfected infants of HIV-infected mothers according to maternal CD4 count and survival (from Newell, et al., Lancet 2004; 364: 1236) % Mortality

  7. Identifying Gaps: Maternal careUganda Oct 07-08 *From Oct 07 to March 08: 14,967 women tested, 1157 (7.7%) were positive, 794 (68.6%) received prophylaxis. From April to June 08: 4,652 women tested, 498 (10.7%) were positive, 753 received prophylaxis (105 multi-drug and 191 HAART: suggesting that most of the women receiving multi-drug and HAART were know HIV infected women who became pregnant while on therapy.

  8. Identifying Gaps: Exposed child Follow-up 1st quarter O8, Uganda

  9. ARVs given to HIV+ pregnant women who present in ANC or in L & D.AR Tanzania. Quarter ending 30 Jun 2008 • 30,000 pregnancies • 56% Tested • 47% any ARV

  10. Exposed infants at Mwanza, TZ sites • Many mothers and children do not return for care- but number unknown • Some with (+) PCR never returned for result • Some with (+) 1st PCR had (-) 2nd PCR (error?) • About 25% of those who got PCR were (+) • Advised to wean at 6 months- effect on infant survival? No data. • PIs not being used in any infants • Conclusion: There is no evidence of benefit, and reason to be concerned regarding harm from early weaning and NVP resistance.

  11. Plugging the Gaps • Adequate ARV therapy for pregnant women and new mothers • Adequate prophylactic coverage of infants • Protocol driven medical follow-up and testing of infants

  12. Strategies: preserving maternal health • Earlier initiation of HAART in HIV positive women

  13. Strategies: preventing transmission to infants ARV prophylaxis to protect breast feeding infants. • Promote the use of HAART in HIV positive pregnant women for the duration of pregnancy and breast-feeding. • Data on maternal HAART more “mature”

  14. Enroll into Care Provide a package of support for HIV-exposed infants • All infected pregnant women and exposed infants are being routinely enrolled into HIV care and treatment programs • Robust infant nutrition counseling • Starting in antenatal period and continuing through infancy • Evidence-based counseling: risk of HIV infection or death from substitute feeding for the individual infant • proper guidance for women on how and what to feed the infant once weaned • Facilitating the general availability early infant virologic diagnosis • Training on site level DBS collection techniques • Emphasize clinical diagnosis in interim

  15. 3. Scripted Care • Implementing exposed infant medical records to assist with proper procedural care and testing. • What should be done at each visit. • Collects relevant clinical data

  16. Strategies: Comprehensive follow up for mothers and exposed children • Community outreach initiated by the HIV care and treatment clinic. • key to integration into HIV care and treatment program. • Engage the HIV exposed child into care until sero-status known and exposure ended. • Ongoing follow-up of infants testing negative until ?: 18 months, 24 months, 36 months

  17. Help going forward • Funding to HIV care and treatment clinics to develop and improve Maternal-child HIV care as part of their overall HIV care services. • Advocate changes in national guidelines to permit earlier initiation and use of HAART in-lieu of multi-drug prophylaxis.

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