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Imoudu

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  • 1. AN UPDATE ON PAEDIATRIC HIV/AIDS AND CHALLENGES OF MANAGEMENT IN NIGERIA By IMOUDU I A MODERATOR DR UMAR L W
  • 2. OUTLINE  Introduction  Epidemiology – Global, regional & National  Pathogenesis, transmission, disease progression  Clinical manifestations, associated conditions, Ois, clinical staging  Diagnosis , lab evaluation.  HIV Testing & counselling – PITC  Mx  ART –ARVs , Eligibility, initiation, monitoring, adherence, toxicities ,  Paediatric HIV/AIDS in Nigeria – Hx, Current position, prospects; Strategic plan;  Challenges, strengths, & opportunities  conclusion
  • 3. INTRODUCTION  HIV IS A RETROVIRUS WHICH BELONGS TO THE FAMILY LENTIVIRIDAE  THE VIRUS MAINLY INFECTS HELPER T LYMPHOCYTES,MONOCYTES AND MACROPHAGES  AIDS RESULTS FROM PROGRESSION OF HIV INFECTION.
  • 4. INTRODUCTION.  HIV WAS FIRST RECOGNIZED IN THE USA IN 1981. ISOLATED IN 1983. DEMONSTRATED AS THE CAUSATIVE AGENT OF AIDS IN 1984. A SENSITIVE ELISA TEST WAS DEVELOPED IN 1985.
  • 5. EPIDEMIOLOGY  AT THE END OF 2007,WHO ESTIMATED THAT ABOUT 33.2MILLION PEOPLE WERE LIVING WITH HIV GLOBALLY.  16% DROP WHEN COMPARED WITH THE 2006 ESTIMATE OF 39.5MILLION.  THE NUMBER OF PEOPLE LIVING WITH HIV IN EASTERN EUROPE AND ASIA HAS INCREASED BY OVER 150% FROM 630000 IN 2001 TO 1.6MIL IN 2007.  330000 CHILDREN DIED OF AIDS GLOBALLY IN 2007.
  • 6. Global summary of the AIDS epidemic December 2007(WHO) Number of people living with HIV in 2007 Total 33.2 million [30.6 – 36.1 million] Adults 30.8 million [28.2 – 33.6 million] Women 15.4 million [13.9 – 16.6 million] Children under 15 years 2.5 million [2.2 – 2.6 million] People newly infected with HIV in 2007 Total 2.5 million [1.8 – 4.1 million] Adults 2.1 million [1.4 – 3.6 million] Children under 15 years 420 000 [350 000 – 540 000] AIDS deaths in 2007 Total 2.1 million [1.9 – 2.4 million] Adults 1.7 million [1.6 – 2.1 million] Children under 15 years 330 000 [310 000 – 380 000]
  • 7. EPIDEMIOLOGY • SSA STILL MOST AFFECTED ,68% ADULTS AND 90% CHILDREN LIVING WITH HIV. • SSA ACCOUNTED FOR 76% AIDS DEATHS IN 2007. • 1.7MILLION NEW INFECTIONS IN 2007.
  • 8. EPIDEMIOLOGY • NGR HAS THE HIGHEST BURDEN OF MTCT RATES AND PEADIATRIC HIV DISEASE IN THE WORLD. • NGR IS ESTIMATED TO HAVE 290,000 CHILDREN LIVING WITH HIV. • ACCOUNTS FOR 14% OF THE TOTAL AFRICAN BURDEN. •STATE-WIDE HIV PREVALENCE IN NGR RANGES FROM AS LOW AS 1.6% IN EKITI TO 10% IN BENUE.
  • 9. PATHOGENESIS
  • 10. MODE OF TRANSMISION. • MATERNAL TO CHILD. • USING CONTAMINATED SKIN PIERCING INSTRUMENTS OR SHARPS. • INJECTION OR TRANSFUSION OF CONTAMINATED BLOOD OR BLOOD PRODUCTS.
  • 11. MODE OF TRANSMISION. • UNPROTECTED SEXUAL INTERCOURSE WITH AN INFECTED PARTNER. • WITHOUT INTERVENTION,5-10% OF TRANSMISION WILL OCCUR DURING PREGNANCY,10-20% DURING LABOUR AND 5-20% DURING BREASTFEEDING. • 15-30% OF NON-BREASTFED CHILDREN WILL BE INFECTED OVERALL.
  • 12. Risk Factors For Maternal To Child Transmission Maternal Factors  Mothers with high viral load  Severe immunosuppression and advanced disease  Rupture of membranes > 4hrs before delivery.  Cracked nipples and breast abscesses during breastfeeding.  Maternal micronutrient deficiencies.
  • 13. Duration of ROM and risk of transmission < 4 hours > 4 hours 14% 25%
  • 14. The effect of maternal viral load on the risk of transmission of HIV <1000cpm 12% Transmision >10,000cpm 29% Transmision
  • 15. RISK FACTORS FOR MTCT INFANT FACTORS. – INVASIVE INFANT PROCEDURES DURING DELIVERY – FIRST TWIN – PREMATURITY – BREASTFEEDING – ORAL THRUSH OR ORAL ULCERS WHILE BREASTFEEDING
  • 16. CLINICAL MANIFESTATION. PRIMARY ACUTE INFECTION. • I P IS 2-4WKS FOR 10 INFECTION ACQUIRED BY ADULTS AND ADOLESCENTS. • NON-SPECIFIC SYMPTOMS OCCUR IN 30-90% OF NEW INFECTIONS. • FEVER,FATIGUE,MALAISE,PHARYNGITIS, LYMPHADENOPATHY.
  • 17. CLINICAL MANIFESTATION. LATE STAGE DISEASE. • CHARACTERIZED BY IMMUNODEFICIENCY • RESULTING IN SUSCEPTIBILITY TO INFECTIONS,MALIGNANCIES AND ENCEPHALOPATHY
  • 18. CLINICAL STAGING IMPORTANCE • CLARIFIES THE PROGNOSIS OF INDIV PATIENTS. • AIDS IN DIAGNOSIS IN THE ABSENCE OF LAB TESTING. • AFFECTS THE TYPE OF TREATMENT INTERVENTIONS INCLUDING INDICATIONS FOR STARTING AND/OR CHANGING ART.
  • 19. WHO Paediatic Staging Of HIV/AIDS Disease Stage 1 Asymptomatic Persistent generalized lymphadenopathy Stage 2 -Hepatosplenomegaly -Papular pruritic eruptions -Seborrheic dermatitis -Fungal nail infection - Angular chelitis -Lineal gingival erythema -Extensive HPV or molluscum infection (>5% of body area/face) -Recurrent oral ulcerations (>2 episodes/6mos) -Parotid enlargement -Herpes zoster (>1 episode/12 mos) -Recurrent or chronic URTI: otitis media, otorrhea, sinusitis -(>2 episodes/ 6mos) -unexplained moderate malnutrition not responding to standard therapy
  • 20. Stage 3. - Unexplained persistent diarrhoea (> 14days) - Unexplained persistent fever (intermittent or constant, > 1mo) - Oral candidiasis (outside neonatal period) - Oral hairy leukoplakia - Pulmonary TB. - Severe recurrent bacteria pneumonia (>2 episodes/12 mos) - Acute necrotizing ulcerative gingivitis/ periodontitis. - LIP,lymph node TB - Unexplained anaemia (< 8g/dl),neutropenia (<1000/mm3 ) or thrombocytopaenia (<50,000/mm3 ) for > 1mo. - Chronic HIV associated lung disease.
  • 21. •Stage 4 •Unexplained severe wasting or severe malnutrition not responding to standard therapy. •Pneumocystis pneumonia •Recurrent severe presumed bacteria infections (e.g empyema, pyomyositis, bone or joint infections, meningitis, but excluding pneumonia). •Chronic herpes simplex infection: (orolabial or cutaneous of more than 1mo duration). •Extrapulmonary TB •Kaposis sarcoma •Esophageal candidiasis •CNS toxoplasmosis (outside the neonatal period). •HIV encephalopathy. •CMV infection (retinitis or infection of organs other than liver, spleen or lymph nodes: onset at age 1mo or more)
  • 22. •Extrapulmonary crytococcosis including meningitis. •Any disseminated endemic mycosis (e.g extrapulm histoplas mosis, coccidiomycosis, penicilliosis) •Cryptococcosis •Isosporiasis •Disseminated non-tuberculous mycobaterial infection. •Candidiasis of the trachea, bronchi or lungs. •Visceral herpes simplex infection •Acquired HIV associated rectal fistula •Cerebral or B cell non- Hodgkin lymphoma. •Progressive multifocal leukoencephalopathy (PML). •HIV associated cardiomyopathy or nephropathy.
  • 23. WHO classification of HIV-associated immunodeficiency in infants and children Classification of HIV- associated immunodeficiency Age-related CD4+ values/percentages ≤ 11 months (%) 12-35 months (%) 36-59 months (%) ≥ 5 years (cells/µl) Not significant >35 >30 >25 >500 Mild 30-35 25-30 20-25 350-499 Advanced 25-29 20-24 15-19 200-349 Severe <25 <20 <15 <200 or <15% *Total Lymphocyte Count (TLC) <4000 cells/µl <3000 cells/µl <2500 cells/µl <2000 cells/µl
  • 24. Laboratory Diagnosis Antibody tests.  HIV rapid tests  HIV enzyme-linked immunosorbent Assay [ELISA]  Western blot. Antigen Detection Methods.  HIV DNA polymerase chain reaction (PCR)  HIV RNA PCR  P24 antigen detection  Viral culture.
  • 25. INTERPRETATION OF RESULTS  HIV infection is absent if there are at least 2 negative antigen detection tests between the age 1mo and 6mos  Loss of HIV antibody in a child with previously negative antigen detection tests confirms that the child is not infected.  HIV infection is present if they are 2 positive viral tests on separate blood samples regardless of age.
  • 26. INTERPRETATION OF RESULTS  2 or more negative antibody tests performed by the age of over 6mos with an interval of at least 1mo between the tests reasonably excludes HIV infection in exposed children.  A positive HIV antibody test at > 18mos followed by a positive confirmatory test definitely indicates HIV infection.
  • 27. COUNSELLING • A process by which a counsellor provides adequate information and education about a situation and helps the client to make an informed choice of what is best to do in that situation . • An integral component of the approach to caring for HIV infected/affected children, their families and caregivers.
  • 28. COUNSELLING • It is a continuous process that starts from the point of contact with the facility and continues throughout the life of the child.
  • 29. PITC • HIV testing and counselling which is recommended by health care providers to persons attending health care facilities as a standard component of medical care. • The major purpose is to enable specific clinical decisions to be made and /or specific medical services to be offered that would not be possible without knowledge of the child’s HIV status.
  • 30. PITC • PITC is voluntary and the ‘’3 Cs’’- informed CONSENT, COUNSELLING and CONFIDENTIALITY must be observed. • FMOH presently recommends that PITC be offered to all children seen in paediatric health services.
  • 31. MANAGEMENT  Maintenance of good nutrition Vaccinations  Prophylaxis and treatment of opportunistic infections Psychological support for the family Anti-retroviral therapy Management of AIDS defining illnesses Palliative care for the terminally ill.
  • 32. ARVs Nucleoside reverse transcriptase inhibitors (NRTIs ) Some important side effects Zidovudine ( ZDV, AZT ) Anemia, neutropenia ,headaches ,gastrointestinal disturbance. Lipodystrophy. Lamivudine (3TC ) Stavudine (d4T ) Peripheral neuropathy., pancreatitis, lipodystrophy. Abacavir (Abc ) Didanosine (ddL ) Emtricitabin (FTC ) Hypersentitivity reaction. Non- Nucleoside Reverse trancriptase inhibitors (NNRTIS ) Nevirapine (NVP ) Efavirenz (EFV ) Hepatitis CNS Symptoms, increased transaminases Nucleotide Reverse transcriptase inhibitors (NtRTI) Tenofovir (TDF) (disoproxil fumarate) Headache, nausea, diarrhoea, bone demineralization
  • 33. ARVs Protease inhibitors (PIs) Lopinavir (LPV) Ritonavir (RTV) G.I intolerance ,Lipodystropy, hepatitis Nelfinavir (NFV) Diarrhoea, lipodystrophy. Amprenavir (APV) Fusion inhibitors enfuvirtide Local injection site reaction; Hypersensitivity reaction.
  • 34. ARVs  Integrase inhibitors (Raltegravir and Elvitegravir)- currently undergoing clinical trials.  Chemotactic cytokine Receptor (CCR5) inhibitors- undergoing clinical trials  Maturation inhibitors-yet to undergo clinical trials  Use of biological agents - GBV- C  HIV vaccine.  
  • 35. INITIATION OF ARVs • WHO paed stage 3 or 4 irrespective of CD4+%. • WHO paed stage 2 or 1 with CD4+ less than 25% (1500 cells /mic) for children less than 12 months. Less than 20% ( less than 750 cells /mic) for children 12 – 35 months. Less than 15%(350 cells/mic) for children 36-59 months. Less than 15% (200 cells/mic) for children more than 5 years.
  • 36. MONITORING • This can be either clinical or laboratory. • Required at, 1. Base line 2. During care of patients who are not yet eligible for ART 3. Starting ART 4. Maintaining ART
  • 37. ADHERENCE • A partnership between the patient, family and health care team to ensure that medication are taking exactly as prescribed. • Potential barriers;  Complex medication regimens  Difficulty in measuring or administering medications  Dietary requirements and restrictions
  • 38. ADHERENCE  Religious, cultural and personal beliefs about taking medications  High pill/liquid burden  Multiple caregivers who may assume that the other has given the medication  Difficulty with transportation to the clinic for refills and appointments
  • 39. ADHERENCE  Travel away from home or having family members visit  Poor palatability of ARVs  Medication refusal  Medication burn – out.
  • 40. PREVENTIVE THERAPY • PRIMARY PREVENTIVE THERAPY • SECONDARY PREVENTIVE THERAPY • CPT • IPT
  • 41. PEAD HIV/AIDS IN NGR • NGR HAS A POPULATION OF 140MIL. • ANNUAL GROWTH RATE OF 3.6%. • 47% OF TOTAL POPULATION OF W.AFRICA. • FIRST CASE DIAGNOSED IN A 13YR-OLD GIRL IN 1986.
  • 42. PEAD HIV/AIDS IN NGR • FMOH IDENTIFIES AIDS AS ONE OF THE IMPORTANT CAUSES OF DEATHS IN ADULTS AGED 15-49YRS. • FMOH PLANNED TO PROVIDE ART IN 2001. • IMPLIMENTATION STARTED FOR ADULTS IN 2002. • TREATMENT FOR CHILDREN DID NOT BEGIN UNTIL 2004.
  • 43. PEAD HIV/AIDS IN NGR STRATEGIC PLAN • FMOH COMMITTED TO SCALING UP PEAD HIV CARE TO ENSURE THAT AT LEAST 80% OF INFECTED AND EXPOSED CHILDREN HAVE ACCESS TO CARE,TREATMENT AND SUPPORT.
  • 44. PEAD HIV/AIDS IN NIGERIA STRATEGIC OBJECTIVES • PROMOTE NATIONAL COORDINATION • STRENGTHEN THE SYSTEM OF IDENTIFICATION AND TESTING OF NEW HIV POSITIVE CHILDREN • ENHANCE CARE FOR HIV INFECTED AND EXPOSED CHILDREN • EXPAND HUMAN RESOURCES
  • 45. PEAD HIV/AIDS IN NGR STRATEGIC OBJECTIVES • IMPROVE COMMUNITY INTEGRATION • IMPROVE MONITORING AND EVALUATION • INITIATE A SURVEILLANCE PROGRAM TO ASSESS THE NATURE OF PEAD HIV/AIDS.
  • 46. CHALLENGES CHALLENGES TO THE HEALTH SYSTEM • INCREASED BURDEN ON ALREADY OVERSTRETCHED HEALTH CARE SYSTEM • LACK OF ACCESS TO AND POOR UPTAKE OF PMTCT SERVICES • INADEQUATE FACILITIES FOR EARLY INFANT DIAGNOSIS • LIMITED HUMAN RESOURCE CAPACITY TO MANAGE PEAD HIV/AIDS
  • 47. CHALLENGES CHALLENGES TO THE HEALTH SYSTEM • ISSUES AROUND INFANT FEEDING AND COUNSELLING • LACK OF INTEGRATION,POOR LINKAGES AND WEAK REFERRAL SYSTEM • WEAK LOGISTIC MANAGEMENT INFORMATION SYSTEM LMIS • LACK OF REGULAR MONITORING AND EVALUATION OF SERVICES.
  • 48. CHALLENGES SOCIETAL • LOSS OF PRODUCTIVE AGE GROUP • INCREASING NUMBER OF OVC • STIGMA,DISCRIMINATION AND CULTURAL BARRIERS TO EFFECTIVE CARE AND TREATMENT.
  • 49. STRENGTHS AND OPPORTUNITIES • POLITICAL COMMITMENT BY GOVT • WELL SPREAD HEALTH INFRASTRUCTURE • MANY TRAINABLE HEALTH PERSONNEL AND EXPERTS • INCREASED DEMAND FOR HIV/AIDS TREATMENT,CARE AND SUPPORT SERVICES
  • 50. STRENGTHS AND OPPORTUNITIES • LOCAL PRODUCTION OF GENERIC ARVs • INCREASING NUMBER OF IMPLEMENTING PARTNERS
  • 51. CONCLUSION • HIV/AIDS HAS BECOME A SIGNIFICANT CAUSE OF INFANT AND CHILDHOOD MORTALITY AND MORBIDITY IN NIGERIA AND SERIOUS ATTENTION BY BOTH THE GOVERNMENT AND POPULACE SHOULD BE PAID TO ITS PREVENTION AND MANAGEMENT. • ALL HANDS MUST BE ON DECK TO ENSURE THAT THE FMOH’S GOAL OF PROVIDING CARE,TREATMENT AND SUPPORT TO AT LEAST 80% OF THE CHILDREN EXPOSED TO AND INFECTED WITH HIV IS ACHIEVED.
  • 52. THANK YOU
  • 53. REFERENCES • UNAIDS,WHO;Aids epidemic update.Dec,2007. • Hoffman,Rockstroh,Kamps;HIV Medicine 2007. • WHO;Guidelines on PITC 2007. • William W Hay Jr,et al;Current pediatric Diagnosis and Treatment 2007. • FMOH (NGR);National Paediatric HIV/AIDS Guidelines 2007. • FMOH(NGR);Scale-up plan for paediatric HIV/AIDS care,treatment and support oct,2007. • http://en.wikipedia.org • http://www.unaids.org

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