We participated in a workshop recently. The following is the Word format of the Powerpoint report. I experienced difficulty uploading it in powerpoint format.
Facilitators
• Watson Douglas
– Pediatric HIV specialist
IHV-Baltimore; University of Maryland
• Bowman David
– Pediatrician/Clinical Training Director
IHV-Nigeria/Baltimore
• Okechukwu Adaora
– Pediatrician, Gwagalada Specialist Hospital, Abuja
• Nadew Kidest
– IHV-Nigeria
• Adamu Grace
– IHV-Nigeria
• Okundia Patience
– National Hospital Abuja
Institute of Human Virology Nigeria
• Affiliate of Institute of Human Virology, Baltimore
• Dr Dakum, Chief of party
• Professor Blattner, Alashle Abimiku, investigators
• Work closely with Professor Robert Gallo, co-discoverer of HIV
• The ACTION (AIDS Care and Treatment in Nigeria) Project so sets out reduce the incidence HIV/AIDS in Nigeria
Arrival
• Meant to have been on the 23rd
• I arrived on Monday the 24th
• I was on call the previous day
• I met the 2nd session
• Accommodation was splendid
• The food was good
• We had a Pre-test
Thrust of the Workshop
• Focus on Pediatric HIV/AIDS care
• Reduce the incidence of HIV/AIDS by prevention and treatment of pediatric HIV in Nigeria
• Build comprehensive pediatric HIV care for Nigeria
• All that prescribe pediatric ARVs must do it right
• Prevent multi-drug resistance
• Intimate workers in new sites with IHV’s potentials and planned work in Nigeria
• Raise awareness about GON intended harmonization of HIV care in Nigeria
• Build capacity to be able to achieve above
• Workshop overview
• We had a Pre-test
• The burden of pediatric HIV
• Globally (UNAIDS 2005 figures): 2.3million (5.7% of total) children living with HIV
• 700,000 (14% of total) new infections/year
• 1900 infections per day
• Above preventable by good PMTCT
• 570,000 (18% of total) deaths/year
• 1560 deaths/day-mostly preventable by early detection, prophylaxis and treatment
• Most of these in sub-Saharan Africa
• 13million orphans worldwide-90% in Africa
• By 2010, 25million AIDS orphans
• In Nigeria (FMOH 2004 figures): estimated 4.4% National prevalence
• 3.5million Nigerians living with HIV-third highest worldwide next to south Africa and India
• 1.7million women
• 270,000 Nigerian children lives with the virus (14% of total African burden)
• 847,000 Nigerian children orphaned by HIV
• Next, we considered, broadly, steps needed to prevent and treat pediatric HIV starting by reminding ourselves that-HIV can be treated
-HIV can be prevented
-treatment/prevention require dedication, cooperation and a team approach
-resistance is a serious threat
We examined the HIV structure, its pathogenesis, history and manifestations; HAART as criterion for successful viral suppression, mechanism of developing resistance and the draft revised WHO guidelines for initiating ART in children
• Draft revised WHO guidelines for initiating ART in infants and children: clinical criteria
• Stage <18mths>18mths
1 CD4-guided CD4-guided
2 CD4-guided CD4-guided
3 Treat all Treat all,
(consider TB,
LIP, OHL, ITP,
CD4 count)
4 Treat all Treat all
• Draft revised WHO guidelines for initiating ART in children: immunologic criteria
• Marker Age at initiating ART
<12>5yrs
CD% 25% 20% 15% 15%
CD4
count 1500 750 350 200
• We then began to broach the task of building a comprehensive pediatric HIV care in Nigeria
• Systems approach-multiple disciplines
• Standards of care-harmonization of care
PMTCT
• Targets
– Prevent young women from infectn
– Prevent unintended pregnancy in HIV+ women
– Prevent HIV+ women from transmitting to their children
– Provide HIV care, treatment, support to HIV+ women, their infants and their families
UPDATES
• Nobody should prescribe single dose NVP for women in labor (i.e. without protecting the “tail”) for prophylaxis because of risk of resistance in mother
• A single mutation of the HIV leads to resistance to NVP; NVP takes 3-7 days b4 it clears from the bloodstream; mutation/resistance develops in the presence of inadequate drug
• Also, to prevent resistance in infants, protect NVP “tail” by giving AZT + 3TC for 1wk thereafter continuing with AZT for 5wks
• WHO encourages standard practice in all facilities
ARVs FOR PMTCT: INFECTION RATES AT 1MTH
• Effectiveness depend on duration and intensity of ARVs
• No intervention: 20% infected
• Single-dose NVP: 12% infected
• AZT from 28 wks: 7% infected
• 2 drugs: 1-4% infected
• HAART: <1% infected
• There are different scenarios
– Pregnant woman who is HAART eligible
– HIV+ woman on HAART who got pregnant
– HIV+ pregnant woman who is not HAART eligible
– HIV+ positive pregnant woman who is/who is not on HAART but developed TB
– HIV+ woman who will breastfeed after delivery
Different other scenarios beyond the scope of this report
Many health facilities pledged to review their policy on PMTCT
CONCERNS
• Resistance
– NVP
– AZT good drug, needs 5 mutations for resistance to develop
– Mutation to 3TC beneficial overall
– Efavirenz teratogenic in early pregnancy so delay till 3rd trimester
– DDI causes infantile lactic acidosis
– AZT: anemia in newborn
– TDF: ?bone toxicity
– Neurodegenerative mitochondrial brain disease if AZT + 3TC started from 23-32wks gestation and continued in neonates 6wks in the postpartum period
THE DILEMMA OF FEEDING THE HIV-XPOSED INFANT
• We considered this thorny issue
• No easy answers
• Especially its implications for resource-poor settings
• HIV is transmitted to about 15% of exposed infants after 24mts of breastfeeding; exclusive breastfeeding cuts this risk by half; most women do mixed feeding;
• Infant breast milk substitute (BMS) is encouraged but not imposed on the woman
• BMS must satisfy WHO’s AFASS criteria: acceptable, feasible, affordable, sustainable, safe
• Institute appropriate ARV therapy: infant/mother
• Do not allow mixed feeding
• Supplementary feeds: breast with clear fluids-tea, water
• Complementary feeds: breastfeeding + semisolids especially at weaning
• Mixed feeds: any of above 2 + another milk
DIAGNOSIS OF THE HIV EXPOSED INFANT
• Challenging
• Clinical
• Serologic: detects antibody response to infection-rapid tests; have to wait for 18mths for full seroreversion in neonate
• Virologic: Directly detects virus in cell or plasma 2-4wks after infection-viral load testing by DNA PCR; available in some centers
• Immunologic: effect of infection on the immune system-CD4 count or %
Presumptive diagnosis of HIV in infant (WHO 2006 guideline)
• When there is no DNA PCR
• Infant seropositive
and either
pediatric stage 4 disease
or
2 or more of:
-oral thrush
-severe pneumonia
-severe sepsis
Supporting evidence:
-death or advanced HIV in mother
-CD4< 20%
Paediatric stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy
– Lymphadenopathy is a good prognostic sign- probability of death in HIV-infected children with adenopathy is half as much as those without
Paediatric stage 2
• Unexplained persistent hepatosplenomegaly
• Papular pruritic eruptions
• Extensive wart virus infection
• Extensive molluscum contagiosum
• Recurrent oral ulcerations
• Unexplained persistent parotid enlargement
• Lineal gingival erythema (red line along the gum line)
• Herpes zoster
• Recurrent upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis )
• Fungal nail infections
Paediatric stage 3
• Moderate unexplained malnutrition not adequately responding to standard therapy
• Unexplained persistent diarrhoea (14 days or more )
• Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month)
• Persistent oral Candida (after first 6 weeks of life)
• Oral hairy leukoplakia
• Acute necrotizing ulcerative gingivitis/periodontitis
• Lymph node TB
• Pulmonary TB
• Severe recurrent bacterial pneumonia
• Symptomatic lymphoid interstitial pneumonitis (LIP)
• Chronic HIV-associated lung disease including bronchiectasis
• Unexplained anaemia (<8.0 g/dl ), neutropenia (<0.5x109/L) or chronic thrombocytopenia (<50 x 109/ L)
Paediatric stage 4
• Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
• Pneumocystis pneumonia
• 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 month’s duration, or visceral at any site)
• Extrapulmonary TB (except lymph node TB)
• Kaposi sarcoma
• Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
• Central nervous system toxoplasmosis (after the neonatal period)
• HIV encephalopathy
Paediatric stage 4 (cont.)
• Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting another organ, with onset at age over 1 month
• Extrapulmonary cryptococcosis including meningitis
• Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis)
• Chronic cryptosporidiosis (with diarrhoea )
• Chronic isosporiasis
• Disseminated non-tuberculous mycobacteria infection
• Acquired HIV-associated rectal fistula
• Cerebral or B cell non-Hodgkin lymphoma
• Progressive multifocal leukoencephalopathy
• HIV-associated cardiomyopathy or nephropathy
Differentiating pulmonary disease in paediatric HIV (2)
• TB
– Common- about half of people with HIV
– Less likely to be cavitary, more likely to be pneumonia or extrapulmonary versus non-HIV
– HIV patients do poorly if not treated
– PPD useful if positive
– Smear culture can be done in children with right sampling technique, but not widely available
• LIP
– Chronic, slowly progressive- often older children
– Cough, wheeze, hypoxia
– Clubbing may be present (TB usually will kill before clubbing develops)
Differentiating pulmonary disease in paediatric HIV (2)
• Pneumocystis pneumonia (PCP)
– Triad of cough, tachypnea, and hypoxemia
– Acute or subacute, not chronic
– CXR may not be impressive early in disease
• Bacterial pneumonia
– Very common
– Acute presentation
– Usually pneumococcal, but can be many others
• Bronchiectasis
– Chronic with multiple episodes of acute worsening
– CXR shows areas of atelectasis, especially right middle lobe
6 year old with severe distal clubbing secondary to chronic pneumonia
Immunization
• All National EPI immunizations should be given
• BCG
-risk of local adenitis or even disseminated disease; treat with antikoch’s
-benefit outweighs risk
DTP, OPV, Hepatitis B, Measles (may withhold measles vaccine if advanced HIV and measles not active in community
• We had a session examining the new revised pediatric HIV staging (we got a manual) and its bearing on prescribing “ideal HAART” (potent, durable, convenient, non-toxic, tolerable and sustainable).
• We defined HAART as a combination of drugs that is potent enough to stop HIV from growing and requires many different mutations to fail (high genetic barrier to resistance) that the patient takes daily, all doses.
• The real HAART is unsparing-must be taken daily, all doses.
• The issue of resistance to ARVs came up again
• We then began to examine each of the antiretroviral drugs on the PEPFAR list one after the other in some detail-their toxicities, interactions, storage, formulations, palatability, potency, immune reconstitution syndromes e.t.c
• We considered the issue of co-infection of HIV with TB and WHO’s recommendation
• We established that repeated adherence counseling by ALL members of the team is the key HAART success
• The most complication of HAART is resistance
• The treatment of resistance is prevention
• We reviewed the need for excellent ongoing management of the child on HAART
• The role of the family-friendly clinic
• The role of home-based care
• The elements of interval visit
• The place of proper documentation
• The place of adherence
• Treatment failure will occur in some
• ARV specialists must know which drugs to switch to-could be lifesaving
• The workshop facilitators took us through the precursors, mechanisms, indicators, perpetuators of treatment failure
• Successful management of treatment failure is enshrined in a sound knowledge of the different ARV regimen (1st-3rd line) after addressing adherence and the issues listed above
• We again went through the rudiments of post-exposure prophylaxis and universal precaution examining updates about special situations such as rape, PEP following casual coitus, occupational exposure, e.t.c
• An M&E staff of IHV-Nigeria took us through the different PMMs (patient monitoring and management systems) in Nigeria
• He outlined the usefulness of the PMMs-research, patient monitoring, feedback, program evaluation, e.t.c
• Intimated us with the plan of the GON to harmonize all HIV work in Nigeria
• Each day, we reviewed ART cases, the types we encounter in our clinics thus consolidating the theoretical knowledge we were gathering.
• We had a session with our constituency-PLWH/PABA who gave us insightful talks on how we can be more useful in ensuring stigma reduction in the hospital and the society at large
• The workshop ended on Friday evening after we were given some resource materials, certificates, contact information of all participants/trainers.
• We left with a resolve to affect lives
Thanks!!!
