Unit 11 PEDIATRIC HIV INFECTION

Unit Objectives

Describe the magnitude of pediatric HIV Infection Discuss differences between pediatric HIV and adult HIV Describe the use of ART in children Discuss important psychosocial issues concerning pediatric HIV Explain the role of the nurse in Pediatric HIV management

Definition Of Pediatric AIDS (WHO)

Major signs:
Weight loss or abnormally slow growth Chronic diarrhoea of more than 1 month duration Prolonged fever of more than 1 month duration

Minor signs:
Generalized Lymphadenopathy Oropharyngeal Candidiasis Repeated common infections Persistent cough Generalized Dermatitis Confirmed maternal HIV infection
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Definition Of Pediatric AIDS (WHO)

Pediatric AIDS is suspected in a child presenting with at least 2 major signs associated with 2 minor signs in the absence of known causes of immunesuppression, such as cancer, malnutrition or other recognized etiologies

Magnitude of Pediatric HIV Infection

Magnitude of Pediatric HIV In India

Approx. 30% of HIV infected pregnant women will transmit HIV to their babies The estimated number of HIV infected children under 15 years is 4% 80% children born with HIV infection die before the age of 5 years Approx. 20,000 eligible HIV infected children are on ART (NACO, April, 2010)
Source: UNAIDS/WHO/Unicef

How Children Get HIV?

1.80% 1.80%

21.80%

74.50% Mother to child sexual abuse

http://www.indianpediatrics.net/sep2005/953.pdf

blood transfusion others

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Clinical Staging for HIV-infected Children

Stage I

Asymptomatic Persistent generalized lymphadenopathy

Clinical Staging for HIV-infected Children

Stage II

Unexplained Persistent Hepatosplenomegaly Papular Pruritic Eruptions

Extensive Wart virus infection

Extensive Molluscum Contagiosum Recurrent Oral Ulcerations
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Clinical Staging for HIV-infected Children

Stage II(Contd..)

Unexplained Persistent Parotid Enlargement Lineal Gingival Erythema

Herpes zoster
Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis) Fungal nail infections
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Clinical Staging for HIV-infected Children

Stage III

Unexplained moderate malnutrition not adequately responding to standard therapy Unexplained Persistent diarrhoea (14 days or more) Unexplained persistent fever (above 37.5oC, intermittent or constant) for longer than one month Persistent Oral Candidiasis (after first 6-8 weeks of life)
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Clinical Staging for HIV-infected Children

Stage III (Contd..)

Oral Hairy Leukoplakia Acute Necrotizing Ulcerative Gingivitis/Periodontitis Lymph Node TB Pulmonary TB

Severe Recurrent Bacterial Pneumonia

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Clinical Staging for HIV-infected Children

Stage III (Contd..)

Symptomatic Lymphoid Interstitial Pneumonitis Chronic HIV-associated lung disease including Bronchiectasis Unexplained Anaemia (<8g/dl ), Neutropenia (<0.5X 109/L3) or Chronic Thrombocytopenia (<50 x 109/L3)

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Clinical Staging for HIV-infected Children

Stage IV Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy Pneumocystis Pneumonia and Recurrent Severe Bacterial infections (e.g. Empyema, Pyomyositis, Bone or Joint infection, Meningitis, but excluding Pneumonia) Chronic Herpes Simplex Infection; (Orolabial or Cutaneous of more than one months duration or visceral at any site) Extrapulmonary TB ,Kaposi Sarcoma and Oesophageal Candidiasis ( or Candidiasis of Trachea, Bronchi or 14

Clinical Staging for HIV-infected Children

Stage IV (Contd) Central Nervous System Toxoplasmosis (after one month of life) HIV Encephalopathy and Cytomegalovirus infection: Retinitis or CMV infection affecting another organ, with onset at age over 1 month. Extrapulmonary Cryptococcosis (including Meningitis) and Disseminated Endemic Mycosis (Extrapulmonary Histoplasmosis, Coccidiomycosis)
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Clinical Staging for HIV-infected Children

Stage IV (contd..) Chronic Cryptosporidiosis , Chronic Isosporiasis, Disseminated Non-Tuberculous Mycobacteria infection, Cerebral or B cell Non-Hodgkin lymphoma, Progressive Multifocal Leukoencephalopathy , Symptomatic HIV-associated Nephropathy or

HIV-associated Cardiomyopathy

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Indicators of HIV Infection in a Child

Infant: symptomatic with 2 or more signs
Oral thrush Severe pneumonia Severe sepsis

Child: any AIDS indicator signs

PCP Cryptococcal meningitis HIV wasting Extrapulmonary TB Kaposis Sarcoma Stunted Growth/Failure to thrive

Mother:
Advanced HIV disease CD4 < 200 Recent HIV related maternal death
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HIV Testing and Diagnosis

HIV Diagnosis in children<18 months: HIV DNA PCR at 6 weeks and 6 months or 6 to 8 weeks after cessation of breast feeding (where available) HIV antibody testing at 12 and 18 months or 3 months after cessation of breast feeding

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Pediatric and Adult HIV/AIDS: Are they different?

Pediatric vs. Adult HIV/AIDS: Important Differences

Area of Focus Diagnosis Children DNA PCR for children <18 months OR Confirmatory antibody test after 18 months CD4% for children below 5 years of age CD4 for children above 5 years Have higher viral loads More rapid Adults Confirmatory antibody test usually by 6 months after infection CD4 Have lower viral loads Less rapid

Monitoring

Disease Progression

Opportunistic Infections

Often present as primary disease with more aggressive course Have more frequent recurrent invasive bacterial infections (otitis media, respiratory infections) More chance of CNS involvement PCP Failure to thrive

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Changing Times!
HIV in children today a chronic, manageable disease with prolonged survival Children with HIV infection from birth are now surviving to adolescence and adulthood
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Nurses Role: Pediatric HIV Management

Nurses Role: Primary Care HIV Exposed Infants

Suspect and recognize HIV exposed infants Ensure PCP prophylaxis (cotrimoxazole- 5mg/kgonce a day dose for 6 months) Review for TB at each visit Make prompt referral for needed services Educate parents to
Give immunizations as per schedule Bring infant for routine evaluation of growth and development Report any illnesses for prompt treatment Provide good nutrition to the baby 23 Avoid Harmful Child Rearing practices

Nurses Role: Nutrition Education

Feeding options during infancy:
Exclusive breast feeding for 4 months OR Exclusive artificial (Replacement) feeding

Well balanced diet

Small frequent feeds

Food hygiene
Link to NGOs and CBOs, for support 24

Nurses Role: Education - Continuing Care

Growth monitoring Diet to support growing needs Prevent
injuries infections

Regular check - ups Recognize and report Nurses involved in continuing care signs of infections can recognise the need for ART and refer patients appropriately Long term care
School Care takers
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Challenges to ART: Pediatric HIV Infection

Starting ARVs is a Balancing Act

Psychological impact Resistance

Therapeutic benefits

Toxicities

Start?
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Normal CD4 counts For Children

< 12 months >1500cells/mm3 1-5 years >1000 cells/mm3 > 6 years >550 cells/mm3

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NACO Guidelines for initiating ART in children

Age < 11 month infant CD4 Count Irrespective of CD4 count, ART to be given

1235 CD4 < 750 cells/mm3 (<20% of total months lymphocytes) 3659 CD4 <350 cells/mm3 (15% of total months lymphocytes) > 5 years old Follow adult guidelines, i.e. initiate ART before CD4 drops below 250 cells/mm3 Start ART if <350 cells/mm3 if symptomatic
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NACO Recommended ARV Drugs

Recommended Pediatric ARV drugs

NRTIs
Stavudine (d4T)* or Zidovudine (AZT) plus Lamivudine (3TC)*

NNRTIs
Nevirapine (NVP)* or Efavirenz (EFV)
* If age <3 years or weight <10 kg, NVP If >3 years or weight >10kg, NVP or EFV

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Nurses Role: Support Coping with ART Challenges

Dislike for medicine Number of medicines Life long period Monitoring taking blood (CBC, LFT ..) Side effects and toxicities could be more Dependence on caregiver for medicine Caregiver may be sick Adherence
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Exercise 1- Case Scenario

Mrs. A is a 29 year old mother. Both A and her two year old daughter, Baby B, are HIV +ve. Mrs. A has been very unwell over the past six months. After treatment for Crytosporiodiosis, she started ARVs. Unfortunately. Whilst, she has recovered from Crytosporiodiosis, her overall health has remained poor. She gets recurrent chest infections. At the clinic, Mrs.A reveals that she frequently forgets to take her ARVs. In further discussion, she informs you that her husband died eight months ago and she is feeling very depressed. At the same clinic appointment, Baby B is also seen by the doctor. The doctor informs Mrs A that Baby B also requires ARV treatment now as her CD4 count has fallen below 200 cells/mm3. B has also been unwell with recurrent chest infections, severe weight loss and now shingles.

Case Scenario Questions Nurses Role - Adherence

What concerns are there over Baby B starting ARV treatment?
What measures are required to ensure that Baby B receives the drugs she requires?

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Answer 1
Mrs. A has been unwell, has lost her husband, is depressed, does not seem to have any other support person. Baby B has lost her father, mother has been unwell, mother is depressed and is too young to be able to take the medicine by herself-dependent

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Answer 2
Check whether the mother has a support person she could confide in Follow up counseling for the mother for available support services. Probable treatment for depression for the mother . Reinforcement for the need to adhere to medicines. Inform mother on benefits of medication for herselfpossibility to live more healthily and thus will be there for the child for a longer period . Check for support person to see that B also has someone else on whom she could depend on to get her medication.
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Psychosocial Issues: Pediatric HIV Infection

Disclosure of Diagnosis
Age-appropriate information
Its better that he / she doesnt know?

Disclosure
of parents diagnosis to family / friends to school

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Disclosure of Diagnosis
Some of the possible questions could be: When should the child know? When should the child know about the parents diagnosis if the transmission from parent to-child? When should the sibling be told? What may be some of the issues faced by siblings(eg siblings possible perception that HIV infected child gets more attention etc? Should the school/family and friends know why & when?
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Stigma & Discrimination

If you come to know that there is a HIV infected child studying in the school, where your child is also studying. Would you: - Insist to the school authorities that the HIV infected child should be separated with rest of the children? - Instruct your child not to interact with this child?

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Childs Concerns
Chronic illness Why me, May blame parents Taking medicines for many years Antiretroviral drug resistance Handling different stages of development Life planning goals

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HIV infected Adolescents

Scenario 1: Adolescent infected from birth Scenario 2: Adolescent infected through sexual behaviors

What are the psychosocial issues that the adolescent faces?

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HIV infected Adolescents

How would you aid the adolescent in coping with other challenges:
Medication Adherence

Side effects
Family factors Stigma

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Key Points
Nurses have a key role in Prevention of Parent to Child Transmission of HIV Pediatric HIV progresses faster and is more aggressive disease Nurses could play an important role in educating HIV + mothers on primary and follow up care of their babies till diagnosis is confirmed ART could improve the immune system of the child but comes with several challenges Nurses have an important role in supporting and linking HIV+ children and their families to support groups

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Thank You!