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Slide 1 - Technical and Operational issues in Pediatric HIV/AIDS DR. KANUPRIYA CHATURVEDI DR. S.K. CHATURVEDI
Slide 2 - LESSON OBJECTIVES To have an understanding of the magnitude of the problem of Paediatric AIDS Problems and challenges related to Paediatric HIV/AIDS Response to Paediatric AIDS with special response to India
Slide 3 - INTRODUCTION HIV is the greatest health crisis the world faces today. Estimated 40million people living with HIV 2.7 million children under 15 years are estimated to be infected with HIV
Slide 4 - Global Scenario HIV is the greatest health crisis the world faces today. Estimated 40 million people living with HIV 2.7 million children under 15 years are estimated to be infected with HIV 570,000 children died of AIDS in 2005 Children account for 18% of the 3.1 million AIDS deaths Only 40,000 or 4% of the approximately one million people now on treatment are children.
Slide 5 - Indian Scenario Estimated 202,000 children affected by HIV/AIDS. New cohort of approximately 50-60,000 HIV infected infants is added every year Less than 10% of HIV-positive expectant mothers are benefiting from ARV prophylaxis
Slide 6 - Aetiology Caused by the Human Immunodefiency virus Types I and II Type I - Worldwide Type II - Common in West African
Slide 7 - Transmission Majority (90%) infected children acquire the infection through MTCT This occurs during pregnancy, delivery and breastfeeding In absence of any intervention, the risk of MTCT is 15 – 30% in non breast feeding populations Breastfeeding increases the risk by 5 – 20% to a total of 20 – 45%. MTCT rates are <5% in US and Europe with access of appropriate treatment In utero 25 – 45% Intrapartum 65 – 70% - most rapid course Postpartum 12 – 15%
Slide 8 - Other Means of Transmission Blood transfusions, blood products and organ/tissue transplants Contaminated needles Scarification marks ? Sexual intercourse
Slide 9 - Factors Affecting MTCT(Maternal) High maternal HIV RNA level Low maternal CD4+ T-lymphocyte count Chorioamnionitis Maternal vitamin A deficiency and malnutrition Co exciting sexually transmitted disease Urea of antiretroviral therapy Clinical states of mother Interpartum hemorrhage Vaginal delivery Artificial rapture of membranes Rapture of membranes >4hours Fetal scalp monitoring Episiotomy
Slide 10 - Transmission Through Breastfeeding Risk is 14% if sero conversion occurs before birth Risk is 29% if during breastfeeding Highest in the first 6 months of life but continues throughout breastfeeding Transmission risk increased by Seroconversion during breastfeeding Mastitis/breast abscess Bleeding nipples High plasma viral load Oral thrush in baby Mixed feeding (including breast milk)
Slide 11 - Prevention of MTCT In 1997, a joint WHO, UNAIDS, and UNICEF policy Statement called for giving women access to voluntary counseling and testing and information to allow them make informed decisions regarding infant feeding. 2001 – (WHO) If a woman has tested positive when replacement feeding is affordable, feasible, acceptable,sustainable and safe (AFASS) avoidance of breastfeeding is recommended Otherwise, exclusive breastfeeding is recommended. It should be short with abrupt cessation Mixed feeding is discouraged as its promotes transmission
Slide 12 - Prevention of MTCT 3 Pregnant women who need ARV treatment should receive it in accordance with WHO guidelines HIV – infected pregnant women who do not have indication for ARV treatment or do not have access to treatment should be offered ARV prophylaxis to prevent MTCT using one of the several regimens know to be safe ZDV from 28wks of pregnancy + single dose NVP during labour and single dose NVP and one week ZDV for infant.
Slide 13 - Prevention of MTCT 4 Nevirapine tab 200mg given to the mother during labour and the syrup 2mg/kg given to baby within 72 hours of life reduces transmission by half This is current practice in India
Slide 14 - CLINICAL FEATURES CNS – microcephaly - progressive neurological deterioration or spastic encephalopathy - developmental delay/regression - predisposition to CNS infections Respiratory System - Recurrent infections (pneumonia, sinusitis, otitis media) - Tuberculosis - Pneumocystis carinii pneumonia or lymphoid interstitial pneumonitis
Slide 15 - Clinical Features 2 CVS – cardiomyopathy with congestive cardiac failure GIT- - AIDS enteropathy (malabsorption, infections with various pathogens) leads to chronic diarrhoea resulting in failure to thrive -Abdominal pains, dysphagia, chronic hepatitis or pancreatitis Renal – AIDS nephropathy: the most common presentation being nephrotic syndrome Skin – Eczema, seborrheic dermatitis, candida infections, molluscum contagiosum, anogenital warts
Slide 16 - Opportunistic infections pneumocystis carinii pneumonia Cyptosporidium Epstein Barr Virus - Measles - Cryptococcus meningitis Toxoplasmosis Malignancy Non Hodgkin’s Lymphoma Primary CNS lymphoma Kaposi sarcoma
Slide 17 - WHO CLINICAL CASE DEFINITION OF PAEDIATRIC AIDS 2 major + 2 minor Criteria MAJOR Weight loss of failure to thrive Chronic diarrhoea > 1 month} Prolonged fever > 1 month } Major
Slide 18 - MINOR SIGNS Generalised lymphadenopathy Oropharyngeal candidiasis Recurrent common infections Generalised dermatitis Recurrent invasive bacterial infection Confirmed maternal HIV infection
Slide 19 - CDC Immunologic categories based on CD4+ and % Total lymphocyte counts
Slide 20 - Diagnosis of HIV Infection Diagnosis of HIV infected children over 18months can be made by antibody test (ELISA and confirmatory tests) Specific diagnosis in children less than 15 -18months can be made by virologic tests HIV DNA polymerase chain reaction (PCR) HIV RNA Assay Standard and immune complex dissociated p24 antigen Viral culture Tests should be performed at 48 hours of age -14 days -1 – 2 months - 3 – 6 months
Slide 21 - HIV infection is absent if there are 2 or more negative viral tests between the age 1 month and 6 months HIV infection is present if there are 2 positive viral tests on 2 separate blood samples regardless of age In the absence of virologic tests 2 or more negative antibody tests performed by the age of over 6 months with an interval of at least 1 month between tests reasonably excludes HIV infection in exposed children A reactive HIV antibody test at >18 months followed by a positive confirmatory test definitely indicates HIV infection.
Slide 22 - TREATMENT MODALITIES Antiretroviral therapy Treatment of acute bacterial infections Prophylaxis and treatment of opportunistic infections Maintenance of good nutrition Immunization Management of AIDS – defining illnesses Psychological support for the family Palliative care for the terminally ill child
Slide 23 - Antiretroviral Therapy Goal is to maximally suppress viral replication to on detectable levels for as long as possible The antiretroviral drugs fall under 4 major categories Nucleoside reverse transcriptase inhibitors (NRTIs) ZDV, ddI, 3TC, d4T Non-nucleoside RTIs, Nevirapine, Efavirenz Protease inhibitors: Nelfinavir, Ritonavir Fusion inhibitors: Enfuvirtide
Slide 24 - Antiretroviral Therapy 2 When to initiate ARV All HIV infected children less than 12 months Clinical AIDS Mild to moderate clinical symptoms Mild to moderate immunosuppression Good response to 2NRT1s +1 protease inhibitor Some studies have shown comparible result with 2NRT1s + 1 NNRT1 Nigeria ARV – Stavudine,Lamivudine, Nevirapine
Slide 25 - Immunization All HIV-exposed infants should be fully immunized Infected and symptomatic infants should receive all vaccines including measles and hepatitis B but not BCG or Yellow fever vaccine Infected and symptomatic children should receive IPV instead of OPV
Slide 26 - Outcome Patterns 15-25% : rapid course median survival 6-9mo if untreated 60-80%: median survival 6yrs <5% : long-term survivors with minimal or no progression, low viral loads for > 8yrs
Slide 27 - ART Programme in India Launched on 1st April, 2004 at 8 institutions in 6 high prevalent states Currently 56 ART centers operational in Medical colleges & some District hospitals Currently 40,000 adults & 1300 children on ART Estimated that about 8,000 - 10,000 children will require ART in 2006/2007
Slide 28 - Issues and Challenges Difficulties in Diagnosis Lack of appropriate formulations Difficulties in dosing Cost of Formulations Lack of trained manpower to deliver care & support Special needs of children affected & infected by HIV/ AIDS
Slide 29 - The Business Case Numbers of children needing HIV/AIDS care and treatment in Asia are small > 50% HIV infected children need ART by 2 years Even with PMTCT will remain significant numbers for next 10-20 years Children often have parents/carers who also need ART Offer the best possible for the future of our children
Slide 30 - Roadmap for Management of Paediatrics HIV/AIDS Expert Committee Meeting and Review of Pediatric Formulations for ARV Treatment for HIV/AIDS (Sept 04, WHO) National Consultation on Children affected or vulnerable to HIV/AIDS (March 05, UNICEF) Technical committee on ART (Dec 2005,NACO) Indian Academy of Paediatrics (IAP ) to finalize Guidelines on all issues related to Paediatrics HIV IAP to finalize ART procurement & Training plan Wider national , International consultations
Slide 31 - Roadmap for Management of Paediatrics HIV/AIDS (contd) First Technical National Consultative Meeting on Pediatric HIV ( Feb 06) Many formal & informal discussions in last 4 months Pediatric Guidelines & Dosing guide finalized Clinton Foundation Pediatric Health Initiative
Slide 32 - Goals Paediatric prevention, care and treatment programme Provide prevention, care and treatment for children infected or affected by HIV/AIDS. Provide ART to at least 90% of children living with AIDS at the end of 5 years Prevent HIV infection through the PPTCT programme scale-up
Slide 33 - Conclusion Paediatric HIV infection is contributing increasingly to childhood morbidity and mortality Most cases result from MTCT Effort should be made prevent MTCT complete care provided for infected children and their families