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Paediatric HIV/AIDS

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Paediatric HIV/AIDS * * * * * * * * * * * * * * References http://hopkins-aids.edu/publications/pocketguide/pocketgd0106.pdf http://www.afro.who.int/home/countries ... – PowerPoint PPT presentation

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Title: Paediatric HIV/AIDS


1
Paediatric HIV/AIDS
2
Introduction 1
  • The epidemic of HIV and AIDS has become a major
    problem in many countries.
  • A very sad aspect of the epidemic is the number
    of young children who are infected.
  • HIV is currently a cause of an increasing number
    of child deaths.

3

Introduction
  • HIV and AIDS is a major cause of infant and child
    morbidity and mortality in Africa
  • Accounts for 7.7 of under-5 child mortality
    worldwide
  • In 2007, AIDS accounted for a rise of gt19 of
    infant and a 36 rise in under 5 mortality rates
  • The high burden of paediatric HIV disease in
    Africa is due to
  • high birth rate
  • high rates of mother-to-child transmission
  • The rapid progression in children is partly
    responsible for the high morbidity and mortality.

4

Introduction cont.
  • Nigeria has the highest burden of MTCT rates and
    paediatric HIV disease in the world
  • About 240,000 children under 15 years old
    accounted for 14 of African burden in 2006
  • The 2008 sentinel survey estimated that 57,000
    new infections occurred in children
  • The number of HIV positive children requiring ARV
    was estimated to be 92,000 in 2008.

5
History of HIV and AIDS
  • Earliest known cases of HIV infection were from
    retrospective studies
  • Stored serum of an individual who died in 1959 in
    leopoldville, zaire
  • A 48 year-old haitian-born sailor (1959)
  • Tissue samples taken from three members of a
    Norwegian family in 1966
  • A teenager in St Louis, Missouri, USA in 1969
  • First HIV infected patients were identified in
    the US in 1981 in gays and IDUs.

6
Early cases of HIV infection and AIDS in Nigeria
  • 1st description in 1986 in Lagos from a sexually
    active 13 year-old girl tested positive to HIV
    antibodies
  • 1st scientific report was on 5 positive cases out
    of 65 individuals screened for HIV antibodies by
    ELISA (1986).

7
Global and regional burden
  • Globally in 2007
  • Number of adult and children living with HIV was
    33 million
  • 2.1 million living with HIV, 370,000 new
    infections and 270,000 deaths occurred in
    children lt15 years
  • Sub-Saharan Africa
  • Is worst affected with 22 million persons living
    with HIV out of which 1.8 million are children
    lt15 years
  • In 2007 1.7 million adult children became HIV
    infected
  • Almost 90 of children with HIV live in
    sub-Saharan Africa.

8
HIV and AIDS burden in Nigeria
  • Nigerian Sero-prevalence Sentinel Survey (2008)
    showed
  • National HIV Prevalence - 4.6 (range 1.0 in
    Ekiti to 10.6 in Benue)
  • No. of PLWHA - 2.95 million (M-1.23, F-1.72
    million)
  • No. of HIV positive infants born - 56,681
  • Cumulative AIDS deaths - 2.99 million (M-1.38,
    F-1.61).

9
HIV and AIDS burden in Nigeria cont
  • Annual AIDS Deaths - 280,000 (M-123,000,
    F-157,000)
  • No. of persons requiring ART - 833,000 (Adult -
    740,000, Children - 92,000)
  • New infections - 380,000 (Adult - 323,000,
    Children - 57,000)
  • No. of children orphaned by AIDS - 2.23 million.

10
Median National HIV sero-prevalence trend
11
HIV Prevalence by States (2008)
12
Biology and structure of HIV
  • Belongs to Lentivirus group of Retroviruses
  • Retroviruses contain reverse transcriptase enzyme
    used for synthesis proviral DNA from viral RNA
  • The mature genome is diploid with 2 identical
    positive sense single-stranded RNA copies
  • The envelope is made of 2 glycoproteins Gp120 and
    Gp41 (HIV-1) and Gp105 and Gp36 (HIV-2)
  • Antibodies to these 2 sets of proteins do not
    usually cross react this differentiates their
    serologic response.

13
Biology and structure of HIV cont
  • Has an outer double lipid membrane (envelope)
    lined by a matrix protein (p17)
  • The lipid membrane is studded with surface
    glycoprotein gp120 and trans-membrane gp41
  • These gp spikes surround the cone-shaped protein
    core (p24).
  • Core protein contains genetic material (RNA) and
    enzymes.

14
Biology and structure of HIV cont
  • Viral enzymes
  • Reverse Transcriptase (RT), converts viral
    single-stranded RNA into a single strand (DNA)
  • Integrase facilitates integration of the double
    stranded DNA into the hosts DNA
  • Protease splits generated macro-proteins into
    smaller viral proteins which get incorporated
    into new viral particles.

15
Molecular Epidemiology of HIV
  • There are two types of HIV
  • HIV 1
  • Found worldwide
  • Main cause of the worldwide pandemic
  • HIV 2
  • Mainly found in W/Africa, Mozambique and Angola
  • Causes a similar illness to HIV1
  • Less efficient transmission, rarely cause MTCT
  • Less aggressive with slower disease progression.

16
Molecular Epidemiology of HIV cont..
  • HIV-1 is classified into subtypes using
    nucleotide gene sequence of gag, pol and env.
  • There are 3 major groups - M (major), N (non-M,
    non-O) and O (Outlier)
  • Group M 9 subtypes (A, B, C, D, F, G, H, J, K)
  • Subtype C
  • Globally predominant commonest in Southern
    Africa and Horn of Africa
  • more often associated with severe immune
    suppression.

17
Molecular Epidemiology of HIV cont.
  • Subtype A commonly seen in Central, West and East
    Africa
  • Subtype B
  • Prevalent in Western Europe and N/America
  • Most knowledge about HIV-1 comes from studies of
    subtype B
  • All HIV-1 subtypes have been found in Africa
  • Recombinant forms of HIV exist
  • A/G recombinant is most predominant in West
    Africa.

18
Molecular Epidemiology of HIV cont.
  • The predominant subtypes of HIV-1 in Nigeria are
    the A/G and G subtypes
  • The A/G subtype is also called Circulating
    Recombinant Form_02/A/G (CRF_02/A/G) 
  • HIV-2 is classified into subtypes A to E and
    recombinant forms have not yet been identified
  • Co-infection or super-infection of an individual
    by HIV-1 and HIV-2 is well documented
  • Infection with different HIV-1 and HIV-2 subtypes
    has also been reported.

19
Natural History of HIV
  • Absolute CD4 count varies with age and is higher
    in healthy children than in adults
  • Normal absolute CD4 counts slowly decline to
    adult levels by 6 years
  • CD4 does not change with age in children 5
    years CD4 is preferred parameter for monitoring
    disease progression
  • Risk of AIDS or death rises as CD4 cell falls
    to lt25 in infants, lt20 from 1-3 years and
    below15 thereafter
  • Prognosis poorer in infants than in older
    children.

20
Modes of HIV transmission
  • Mother-to-child
  • Accounts for gt90 of transmission in children
  • Can occur in-utero, at delivery or during
    breastfeeding
  • Prolonged breastfeeding and mixed feeding in
    Africa are key factors responsible for higher
    transmission rates
  • Without intervention transmission rate is 30-40
  • Sexual abuse
  • Blood and blood product transfusion
  • Contaminated sharps.

21
National Response
  • National Expert Advisory Committee (NEACA) set up
    in 1987 to guide on strategies to control the
    epidemic
  • In 1988 National AIDS and Sexually Transmitted
    Disease Control Programme (NASCP) was established
  • NASCP was renamed as HIV and AIDS Division of the
    Department of Public Health in 2007 which
    coordinates
  • The health sector response to HIV and AIDS
  • Development of policies, guidelines, training
    manuals, SOPs and Job aids
  • Capacity building
  • Monitoring and evaluation of the health sector
  • State AIDS Control programmes have same role in
    states.

22
National Response cont.
  • National Action Committee on AIDS (NACA), their
    state and LGA equivalents (SACA and LACA)
    established in 2000 to coordinate multi-sectoral
    response
  • NACA
  • Developed the 1st multi-sectoral blueprint, HIV
    and AIDS Emergency Action Plan, in 2001
  • Launched the National Policy on HIV and AIDS in
    2003
  • Developed the National HIV and AIDS Behaviour
    Change Communication Strategy (20042008)
  • Launched the Nigeria National Response
    Information Management System (NNRIMS) in 2004
  • Launched the National Strategic Framework
    (2005-2009) in 2005 with all 36 states doing the
    same.

23
National Response cont.
  • In 2007
  • NACA transformed into National Agency for the
    control of AIDS
  • National targets for universal access was
    developed and incorporated in all state strategic
    plans
  • In 2001 FGN planned to put 15,000 people (5,000
    children) on ART
  • In 2003 there was a presidential directive to put
    250,000 persons on ART by June 2005, with 10 as
    children
  • However, paediatric ARVs only became available in
    public health facilities in late 2005
  • As at July 2008, only 17,000 children out of
    estimated 98,000 that required ART were placed on
    treatment.

24
Natural Hx (Clinical Course of illness)
  • Children perinataly infected with HIV fit into 3
    categories
  • Category 1 Rapid progressors ( 25-30)
  • - Die by age 1 year
  • - Usually acquire the infection in
    utero or during early perinatal period
  • Category 2(50-60)
  • - Symptoms developed early in life
  • - Death usually occurs by 3-5yrs
  • Category 3 long term survivors (5 25)
  • - May live beyond 8 years

25
Clinical features of HIV in children
  • ?? History taking in children requires high index
    of suspicion for HIV infection.
  • ?? Usually the symptoms and signs of HIV
    infection in childhood are similar to those of
    other diseases seen in the tropics but they may
    be more severe and occur more frequently
  • ?? The common conditions associated with HIV are
    frequently infectious in nature.

26
(No Transcript)
27
Clinical features contd.
  • Early features are usually non-specific
  • - Fever
  • - Diarrhoea
  • - Failure to thrive
  • - Cough
  • - Generalized lymphadenopathy
  • Later child presents with features that are
    indicative of severe immune suppression
  • - Signs of opportunistic infections
  • - recurrent and more severe forms of common
    illnesses
  • - malignancies

28
Lymphadenopathy
  • Significant lymph
  • Node enlargement
  • is more than 0.5cm
  • in size, at more than
  • 2 sites

29
Kaposi sarcoma
30
Herpes Zoster
31
Molluscum Contagiosum
32
STAGING OF HIV FOR INFANTS AND CHILDREN
  • Staging is a standardized method for assessing
    disease stage/progression
  • All children with HIV infection should be staged
  • Affects the type of treatment interventions,
    including indications for starting and/or
    changing ART

33
  • ?? Clinical and laboratory parameters are used to
    stage HIV disease.
  • ?? There are two international clinical staging
    systems that classify the severity of HIV
    infection in children
  • 1. CDC
  • 2. WHO Paediatric Clinical Staging.
  • ?? The CDC Clinical Staging System Divides
    infected children into 1 of 4 clinical
    categories
  • - Category N (asymptomatic)
  • - Category A (mildly symptomatic)
  • - Category B (moderately symptomatic)
  • - Category C or AIDS (severely symptomatic).

34
  • Although the CDC staging system is more widely
    used in relatively advanced paediatric HIV care
    settings
  • In Africa, the WHO paediatric staging, which
    relies more on readily identifiable clinical
    entities, may be more appropriate for the
    majority of HIV care settings in sub-Saharan
    Africa like Nigeria
  • ?? The WHO Paediatric Clinical Staging System
    also divides HIV infected children into 4
    categories

35
REVISED CLINICAL STAGING WHO 2006
  • Clinical Stage 1
  • Asymptomatic
  • Persistent generalised lymphadenopathy

36
Clinical Stage2
37
Stage 3
38
Stage 4
39
Classification of HIV-Associated Clinical Disease
40
Presumptive diagnosis of severe HIV disease
  • Infant is confirmed HIV antibody positive
  • and
  • -any Stage 4 or AIDS-indicator
    condition or
  • -symptomatic with two or more of
    the following
  • Oral thrush
  • Severe pneumonia
  • Severe sepsis
  • Other factors that support the diagnosis of
    severe HIV disease in an HIV ve infant include
  • Recent HIV-related maternal death or
  • Advanced HIV disease in the mother.

41
WHO Classification of HIV-associated
immunodeficiency in Infants and Children
42
CD4 criteria for severe HIV immunodeficiency (
threshold)
43
Diagnosis and clinical staging
  • HIV Diagnosis in children requires high index of
    suspicion, knowledge and good communication
    skills
  • Diagnosis may be
  • Clinical - based on signs and symptoms, or
  • Clinical supported by laboratory findings
  • HIV and AIDS should be suspected in children with
    suggestive clinical features or HIV-associated
    conditions.

44
Diagnosis and clinical staging cont.
  • All HIV-exposed infants, the sexually assaulted
    and those exposed to potentially infectious body
    fluids should be evaluated
  • If infection is confirmed, clinical disease
    staging should be determined using the WHO
    staging system.

45
Laboratory Diagnosis
  • There are 2 broad categories of tests
  • Antibody detection (reliable in children under 18
    months of age)
  • HIV Rapid test simple and easy to perform
  • ELISA needs more equipment, time, technical
    skills
  • Western blot gold standard but expensive and
    produce indeterminate results.

46
Laboratory Diagnosis cont.
  • Virologic tests (most useful in children below
    the age of 18 months)
  • DNA PCR
  • RNA PCR (plasma viral load) monitors disease
    progression and response to treatment
  • P24 Ag detects window period negative result
    does not rule out infection
  • Culture time consuming, expensive

47
NATIONAL ALGORITHM FOR EARLY INFANT DIAGNOSIS
FOLLOW UP OF HIV EXPOSED/INFECTED CHILDREN
48
ASPECTS OF COMPREHENSIVE MGT
  • Treatment of acute bacterial infections
  • Prophylaxis and treatment of opportunistic
    infections
  • Antiretroviral therapy
  • Maintenance of good nutrition
  • Immunization
  • Management of AIDS- defining illnesses
  • Psychological support for the family
  • Palliative care for the terminally ill child

49
Indications for initiation of ART in children
  • The most important factors to consider when
    assessing eligibility for ART are
  • Age of the child
  • Clinical stage of the disease
  • Immunological stage.

50
Considerations prior to ART
  • Issues to consider in eligible children prior to
    ART
  • Identification of a primary caregiver who
    understands the disease and implications of ART
  • Access to nutritional and family support
    including identification of an informed secondary
    caregiver
  • The status of disclosure to the child / family
  • ART regimen of choice should be guided by
    consideration for limitation of future ARV
    options and potential for resistance
  • Child specific adherence strategy.

51
Considerations prior to ART cont..
  • Access to laboratory monitoring
  • Coexisting illness and conditions (e.g. malaria,
    malnutrition, TB, hepatitis B and C)
  • Presence of active OIs
  • Eligibility for other interventions such as CPT
  • Need for referral to other support services
  • Drug toxicity profile.

52
Pre-treatment evaluation
  • Detailed history, immunization status and
    physical exam
  • Anthropometry (weight, height/length, MUAC, OFC)
  • Neuro-developmental assessment
  • CD4 count/CD4
  • TB screening (Mantoux, chest x-ray, sputum/
    gastric aspirate for AFB)
  • LFTs, urinalysis, E/U/Cr, FBC (and Serum lipids,
    serum amylase, VL if available).

53
Criteria for eligibility for ART
  • The following categories should be considered
    eligible
  • Infants (lt12 months) with confirmed HIV
    irrespective of clinical or immunological stage
  • Children 12 months
  • CD4 lt20 (lt750 cells/µl) if age 12-35 months
  • CD4 lt20 (lt350 cells/µl) if age 36-59 months
  • CD4 lt15 (lt350 cells/µl) if 5 years
  • Must have confirmatory test at 18 months to
    continue with ART.

54
Criteria for eligibility for ART cont
  • Antibody positive children lt18 months with no
    PCR, but with
  • WHO HIV Stage 3 or 4 irrespective of CD4
  • WHO HIV Stage 2 only if CD4 is lt20
  • WHO HIV Stage 1 do not treat if virologic tests
    are not available except if CD4 is lt20 (lt750
    cells/µl)

55
WHO recommendation for ART when CD4 is not
available
  • Children aged lt18 months
  • Infants with confirmed HIV irrespective of
    clinical or immunological stage
  • Children 13-18 months
  • WHO stage 3 or 4, irrespective of total
    lymphocyte count (TLC)
  • WHO stage 2 only if TLC is lt 3000/mm3 or if
    mother has WHO stage 3 or 4 AIDS or died of AIDS
  • WHO Stage 1 do not treat if virological tests
    are not available except if TLC is lt4000/mm.3

56
WHO recommendation for ART when CD4 is not
available cont.
  • Children aged 18 months or older
  • WHO stage 3 or 4 irrespective of TLC
  • WHO stage 2 only if TLC is
  • lt3000/mm3 if aged 18-35 months
  • lt2500/mm3 if aged 36-59 months or
  • lt2000/mm3 if age is 5 years.

57
Antiretroviral therapy
  • Goal of ART To maximally suppress viral
    replication to undetectable levels for as long as
    possible
  • Combination therapy is recommended for all
    infants and children
  • - It slows down disease progression
  • - Improves survival
  • - Results in greater and more sustained
    virological and immunnological response.
  • - Delays development of drug resistant strains
  • NB - ART will not cure HIV infection

58
Highly Active Antiretroviral Therapy (HAART)
  • A combination of 3 or more ARVs from at least two
    different groups
  • Is currently the standard treatment of HIV
    infection aimed at
  • Achieving the best possible suppression of viral
    replication
  • Arresting the progression of the disease
  • Minimizing the risk of interactions, adverse
    effects and
  • Preserving therapeutic options for the future
  • Used as first line ART combination 1st chance
    is the best chance!

59
Classes of ARVs
60
First line ARV regimen
61
Life cycle of HIV showing the points of action of
the ARVs
62
CHOOSING a REGIMEN
NNRTI

NRTI Backbone (2 NRTIs)
OR
Protease Inhibitor(PI)
63
Nevirapine rash
64
Immune Reconstitution Syndromes
  • Characterized by fever, worsening clinical
    signs of the OI symptoms of new OI
  • Occur in the first weeks after starting ART
    (30)
  • May occur with
  • Cytomegalovirus (CMV) infection
  • Varicella-zoster (VZV) infection
  • Cryptococcal infection
  • Progressive multifocal leukoencephalopathy (PML)
  • Mycobacterial infections
  • Pneumocystis jiroveci pneumonia (PCP)
  • Toxoplasmosis
  • Hepatitis B, hepatitis C

65
Routine monitoring of children on ART
  • The child should be seen
  • 2 wks after commencement of therapy
  • Monthly for the first 3 months
  • Thereafter every 3 months except otherwise
    indicated
  • The following should be conducted during
    follow-up visits

66
i. Clinical assessment
  • Growth monitoring using the national growth
    chart
  • Physical examinations (with special attention to
    pallor, jaundice, oral cavity, skin, lymph nodes,
    chest, liver and spleen)
  • Developmental assessment
  • Immunization status
  • Nutritional assessment
  • Psychosocial assessment
  • Adverse ARV effects
  • Review ARV dosages for every 10 increase in body
    weight

67
ii. Laboratory Evaluation
  • CD4 count every 3 months (except otherwise
    indicated)
  • Viral load every 6 months
  • FBC at one month and every 3 months (except
    otherwise indicated)
  • LFTs at baseline and AST and ALT plus bilirubin
    levels every 3 months unless otherwise indicated
    (for patients on NVP these should be done after 1
    month of commencement)
  • E/U, creatinine and urinalysis at baseline then
    every 3 months unless otherwise indicated
  • Serum lipid profile and amylase at baseline, at 3
    months, and thereafter as indicated, where
    possible.

68
ART treatment success
  • Reduction of viral load of at least 1 log by 6-8
    weeks after initiation of treatment
  • Undetectable ( lt200 RNA copies /ml) viral load by
    6 months

69
Adherence to ART
  • Medication adherence is a central feature in the
    success or failure of ARV therapy.
  • Poor adherence may lead to suboptimal levels of
    ARVs, which may facilitate the development of
    drug resistance to one or more drugs in the
    regimen.
  • Long-term poor adherence may lead to
    cross-resistance to other drugs in the same
    class.
  • Medication adherence of 95 (corresponding to
    missing not more than 3 doses per month of a
    twice-daily therapy) or higher is associated with
    the best chance of maximizing success of ART.
  • Adherence refers to a partnership between the
    patient, family and health care team to ensure
    that medication is taken exactly as prescribed.
  • This entails two-way discussions with the patient
    and family to determine plans to incorporate
    medication dosing with current lifestyle.

70
Results of poor adherence
  • ?? Treatment failure
  • ?? Development of drug resistance
  • ?? Development of cross-resistance

71
Routine Monitoring of children who are not yet
eligible for ART
  • The clinical evaluation of infants and children
    who are not yet eligible for ART should be
    performed every 3 months and should include
  • Clinical evaluation
  • Immunological evaluation (CD4 count/ CD4 )
  • Other investigations as clinically indicated

72
Opportunistic infections in HIV
  • Prevalence and severity of OIs ? with HIV disease
    progression
  • Unusual organisms Unusual presentation
  • 2 broad strategies for prevention include
    chemoprophylaxis and immunization.
  • Bacterial infections
  • Bacterial respiratory, enteric diseases etc
  • Mycobacterial infections
  • MTB, MAC
  • Fungal infections
  • Pneumocystis jiroveci pneumonia, Candida,
    cryptococcosis, histoplasmosis,
    coccidioidomycosis, aspergillosis
  • Parasitic infections
  • Toxoplasmosis, cryptosporidiosis,
    microsporidiosis
  • Viral infections
  • CMV, HSV, HZV, HPV, HCV, HBV

73
Immunization of HIV exposed/infected children
  • Give immunizations according to National schedule
  • If the child is not showing any symptoms, all
    vaccines in the schedule can be given, including
    measles
  • If symptoms are present only BCG Yellow fever
    vaccine are contraindicated
  • Other recommended vaccines include
  • -pneumococcal vaccine
  • -Varicella-zoster (chicken pox)
  • -Hepatitis A
  • -Yearly influenza vaccine
  • Avoid missed opportunities for HIV infected
    children who are sick

74
Nutrition
  • Adequate counseling on infant feeding to enable
    the mother make an informed choice as to the
    method of feeding.
  • WHO recommends replacement feeds, if it is
    affordable, acceptable, sustainable and safe
    (AFASS).
  • If not, exclusive breastfeeding for the first 6
    months
  • Mixed feeding must be avoided
  • Micronutrients play critical roles in cellular
    differentiation, enzymatic process, immune system
    reactions and other body functions. Hence they
    are critical in the fight against infections
    pathogens
  • Complementary food should be high calorie and
    rich in micronutrient.

75
Psychological Support
  • Consists of assessment of family support and
    coping mechanism.
  • Counseling to assist the family to cope with the
    social implications of the illness
  • Particularly important where the mother or father
    is also ill with HIV/AIDS and the child faces the
    possibility of being orphaned

76
What we can achieve
77
PRVENTION
  • Primarily, PMTCT.
  • Other measures in adults are also important,
    especially in older children and adolescents

78
Mother-to-Child Transmission of HIV
  • Mother-to-Child Transmission of HIV may occur
    during any of the periods of
  • Pregnancy
  • Labour and delivery
  • Breastfeeding.

79
Maternal risk factors for MTCT
  • High viral load
  • Sexually transmitted infections (STIs)
  • Ante partum hemorrhage
  • Acquisition of new infection in pregnancy
  • Advanced disease
  • Rupture of membranes (premature, prolonged)
  • Prolonged labour.

80
Maternal risk factors for MTCT cont
  • Invasive delivery procedures
  • Instrumental delivery (forceps, vacuum)
  • Episiotomy and genital lacerations
  • Multiple pregnancy (the first twin)
  • Preterm delivery
  • Breast conditions (mastitis, nipple fissures)
  • Placental infection (Viral, bacterial or
    parasitic (e.g. Malaria).

81
Foetal /Infant Risk Factors
  • Genetic characteristics
  • First infant of multiple pregnancy
  • Prematurity
  • Breastfeeding
  • Oral lesions.

82
PMTCT Programme Goals
  • To reduce the transmission of HIV infection from
    positive mothers to their infants.
  • To reduce the proportion of HIV infected infants
    by 20 in 2005 and 50 in 2010.

83
PMTCT Strategy
  • (4-Prong) approach)
  • Primary prevention of HIV in women
  • Prevention of unintended pregnancy in HIV women
  • PMTCT
  • ARV for the mother during pregnancy
  • ARV for the baby at birth and afterwards
  • Good resuscitation practice
  • Good infant feeding practice
  • Prevention, care, support and follow-up services
    for families

84
  • MANAGEMENT OF HIV-EXPOSED CHILD

85
HIV-exposed and HIV-infected infants
  • Definitions
  • HIV-exposed infant is a child of unknown HIV
    status delivered to an HIV positive woman
  • HIV- infected infant is a child whose HIV
    infection status has been confirmed.

86
Immediate newborn care for HIV exposed infants
  • Wipe babys mouth and nostrils with gauze at
    delivery of the head
  • Handle all babies, regardless of HIV status of
    mother with gloves until maternal blood and
    secretions are washed off
  • Keep all babies warm after delivery irrespective
    of maternal HIV status
  • Wash baby immediately after birth with warm
    chlorhexidine solution or wipe dry.

87
Immediate newborn care cont...
  • Use a mechanical suction unit or bulb suction
    only when indicated (e.g. in meconium stained
    liquor)
  • Avoid using mouth operated suction
  • Administer Vitamin K and BCG, ensuring injection
    safety
  • Initiate infant feeding based on mothers choice
  • Give single dose NVP within 72 hours and also
    start ZDV prophylaxis.

88
Follow-up of the HIV- exposed infants
  • HIV-exposed babies should be seen weekly for the
    first 6 weeks including those delivered outside
    health facilities for
  • Check feeding practice and give support
  • Assess
  • Mode of feeding
  • Frequency
  • Duration or quantity
  • Adequacy of supply
  • Bowel habits
  • Check for any other problems.

89
Follow-up of the HIV- exposed infants cont.
  • Check mothers and infants health status
  • Review dosages of ZDV
  • Commence CPT at 6 weeks
  • Collect DBS sample for DNA PCR at 6 weeks or
    first contact if child lt9 months
  • Follow up monthly for the first year of life
  • Plot a growth curve for weight, height, and head
    circumference monthly to monitor growth rate.

90
Follow-up of the HIV- exposed infants cont.
  • Conduct developmental assessment at each visit
    using the developmental check list
  • Abnormal development should raise concerns of HIV
    infection as HIV infected infants are at high
    risk for encephalopathy
  • Give multivitamins (including Vitamin A) until
    HIV is excluded
  • Ensure complete immunization schedule.

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Follow-up of HIV-exposed child cont...
  • Assess all for OIs and treat appropriately
  • Ensure cessation of breastfeeding at 6 months for
    the exclusively breastfed
  • Start complementary feeds at 6 months
  • After age 12 months, follow up every 3 months
    until 18 months when antibody testing should be
    done
  • Refer HIV-infected children for appropriate
    services (ART, Psychosocial care, etc).
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