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  • The World Health Organisation now recommends the use of standard deviation or z scores as a better indicator of malnutrition than growth along the centiles. Z scores describe relative to the population mean for age with a minus 2 z score indicating moderate malnutrition and minus 3 more severe malnutrition.
  • Triomune in adults If quaretr adult triomune underdose NVp seriously. Need fixed dose tablets for younger children - scored
  • 43_Guidelines_Jules.ppt

    1. 1. National Guideline of Care&Treatment of HIV infection in children (Adaptation from the New WHO guidelines August 2006) MUGABO S. Jules M.D TRAC/MOH November 21, 2006
    2. 2. Transmission to child <ul><li>Mother to child: > 95% </li></ul><ul><li>Breastfeeding (also by other than mother) </li></ul><ul><li>Transfusion </li></ul><ul><li>Contaminated materials </li></ul><ul><li>Sexuel </li></ul><ul><li>Tattoos, scarifications, circumcision, dental extractions ... </li></ul>
    3. 3. Infected child Mothers and child antibodies: serology Non infected
    4. 4. How to be sure of HIV infection on a child with HIV + serological test under 18 months ? <ul><li>Proviral HIV DNA or RNA (viral load): sensitivity and specificity nearly 100% after 6 weeks (expensive and unavailable in most limited ressources countries) </li></ul><ul><li>Real time PCR: DNA or RNA : 10-15 $ </li></ul><ul><li>P24 : heated and dissociated </li></ul><ul><li>Dry Blood Spot: Excellent solution- not too expensive </li></ul>
    5. 5. PCR: Sensitivity and specificity <ul><li>If only one (WHO accepts a dg on 1 PCR) </li></ul><ul><li>At 6 weeks for formula feeding </li></ul><ul><li>Anytime if symptoms (or control serology first if older than 9 months old) </li></ul><ul><li>PCR at 5 months to decide stopping breastfeeding </li></ul><ul><li>If asymptomatic: one month after weaning (control first for serology before PCR if > 9 m ) </li></ul><ul><li>DBS prefered but if not available : blood test with 2 ML EDTA tube to do PCR </li></ul>
    6. 6. Biological signs without PCR <ul><li>Serology first from 9 months if mother is HIV+ before doing any PCR </li></ul><ul><ul><li>If + : Do PCR if possible - Continue SMX / TMP and control serology at 18 months </li></ul></ul><ul><ul><li>If – and no breastfeeding since 3 mois: Stop SMX/TMP = sure child is not infected </li></ul></ul>
    7. 7. New WHO recommandations (December 2004- update aug 2006) <ul><li>Clinical diagnosis for children under 18 months with positive HIV serological test: </li></ul><ul><li>2 clinical signs </li></ul><ul><li>1) Sepsis (nessitating IV treatment ) </li></ul><ul><li>2) Severe pneumonia (nessitating 02) </li></ul><ul><li>3) Oral Candidosis </li></ul><ul><li>Or </li></ul><ul><li>AIDS related signs : wasting syndrom, PJP, kaposi, Toxo, encephalopathy, extra pulmonary TB… </li></ul>
    8. 8. Without PCR: very bad specificity and sensitivity <ul><li>Children exposed to HIV are also very exposed to TBC with HIV + parents </li></ul><ul><li>The most confonding disease: TUBERCULOSIS TB:also have pneumomnia and malnutrition with oral thrush and low CD4 very difficult to diagnose in children ( BK rarely +) </li></ul><ul><li>We can still improve sensibility and specificity of these criterias - Important to continue collecting clinical signs /CD4 and compare to gold standard (PCR) </li></ul>
    9. 9. PCR is very important but shouldn’t be an excuse not to give ARV <ul><li>IF presomptive clinical signs of Aids with a child having a positive serological HIV test before 18 months…. </li></ul><ul><li>Decision: </li></ul><ul><li>Food supplementation, Cotrimoxazole, TB treatment and if no improving after 3 weeks = ARV on presomptive signs if PCR not possible </li></ul><ul><li>No gold standard and no possibility to do clinically a difference between disseminated TB and HIV </li></ul><ul><li>Always control HIV serology if child reach 18 months </li></ul>
    10. 10. New WHO recommendations December 2004 and revised in aug 2006 <ul><li>Stadifications similar to adult (4 stages) </li></ul><ul><li>Consider CD4 and Total Lymphocytes </li></ul>
    11. 12. Stage 2 <ul><li>Hepatosplenomegaly </li></ul><ul><li>Recurrent or chronic upper respiratory tract infections </li></ul><ul><li>Parotid enlargement </li></ul><ul><li>Lineal Gingival Erythema (LGE) </li></ul><ul><li>Angular chelitis </li></ul><ul><li>Papular pruritic eruptions </li></ul><ul><li>Seborrhoeic dermatitis </li></ul><ul><li>Extensive Human papilloma virus infection or Molluscum infection </li></ul><ul><li>Herpes zoster </li></ul><ul><li>Fungal nail infections </li></ul>
    12. 14. Stage 3 <ul><li>Conditions where a presumptive diagnosis can be made using clinical signs or simple investigations </li></ul><ul><li>Unexplained moderate malnutrition not adequately responding to standard therapy </li></ul><ul><li>Unexplained persistent diarrhoea (more than 14 days) </li></ul><ul><li>Unexplained persistent fever (intermittent or constant, for longer than 1month) </li></ul><ul><li>Oral candidiasis (outside neonatal period ) </li></ul><ul><li>Oral hairy leukoplakia </li></ul><ul><li>Acute necrotizing ulcerative gingivitis/peridontitis </li></ul><ul><li>Pulmonary tuberculosis </li></ul><ul><li>Severe recurrent presumed bacterial pneumonia (2 or more episodes in 6 months) </li></ul>
    13. 15. Stage 3 <ul><li>Lymphoid interstitial pneumonitis (LIP): Chest X ray </li></ul><ul><li>Full haematologic test: Unexplained Anemia (<8gm/dl), neutropenia (<1,000/mm3) or thrombocytopenia (<30,000/ mm3) for more than 1 month </li></ul><ul><li>Chronic HIV associated lung disease including brochiectasis </li></ul>
    14. 17. Stage 4 <ul><li>Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy </li></ul><ul><li>Pneumocystis pneumonia </li></ul><ul><li>Recurrent severe presumed bacterial infections (2 or > episodes within one year e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia ) </li></ul><ul><li>Chronic orolabial or cutaneous Herpes simplex infection (of more 1 month duration) </li></ul><ul><li>Extrapulmonary tuberculosis </li></ul><ul><li>Kaposi's sarcoma </li></ul><ul><li>Oesophageal Candidosis </li></ul><ul><li>CNS Toxoplasmosis </li></ul><ul><li>HIV encephalopathy </li></ul>
    15. 18. Without ARV-Many things to help <ul><li>Social and psychological support </li></ul><ul><li>Exclude TB </li></ul><ul><li>Do surch for TB actively asking systematic questions: Chronic cough and fever </li></ul><ul><li>Prophylaxy cotrimoxazole </li></ul><ul><li>Nutrition </li></ul>
    16. 19. TB is very difficult to diagnose on HIV+ children (Pulmonary and disseminated TB) <ul><li>Gastric lavage often negative (10 % only +) </li></ul><ul><li>PDD often negative because of immuno suppression </li></ul><ul><li>Scores ( Crofton) : guidelines PNILT but not very good specificity and sensitivity </li></ul><ul><li>Chest X-ray not always significative and often very bad quality </li></ul><ul><li>Abdominal ultrasound: need trained doctors and materials but can help for diagnosis </li></ul>
    17. 20. NEW WHO - April2006 Le Poids La Taille ANTHTROPOMETRIE
    18. 21. WHO Z-score charts WHO recommends the use of z scores rather than centiles Z score charts indicate scores ranging from -3 to +3 A z score of -2 indicates moderate malnutrition and a z score of -3 or below indicates severe malnutrition
    19. 25. Prophylaxy <ul><li>Pneumocystis - Toxoplasmosis- Infections: </li></ul><ul><li>CMX prophylaxy for all: </li></ul><ul><ul><li>Exposed children: SMX/TMP: 25 mg/5 mg /kg OD from 6 W until HIV infe c tion is excluded (PCR or serology) </li></ul></ul><ul><ul><li>HIV infected children < 5years </li></ul></ul><ul><li>HIV infected children > 5 years: Consider WHO clinical stage or CD4 before initiating CMX prophylaxy ( WHO stage 2,3 and 4 or CD4 < 350/ ul) </li></ul><ul><li>If a llergy on CMX: </li></ul><ul><ul><li>Desensibilisation </li></ul></ul><ul><ul><li>D apsone 2 mg/kg if necessary ( but expensive) </li></ul></ul>
    20. 26. 1/2 co 400/80 mg 1/2 co 400/80 mg 1/2 co 400/80 mg 1,5 co 100/20 mg 1,5 co 100/20 mg 1 co 100/20 mg 1 co 100/20 mg / 25/5 mg/kg OD Bactrim® co 6 ml 5,5 ml 5 ml 4,5 ml 4 ml 3 ml 2,5 ml 2 ml 25/5 mg/kg OD Bactrim® sirop 200 mg/40 mg/5ml 10 kg 9 kg 8 kg 7 kg 6 kg 5 kg 4 kg 3 kg Dose Weight kg
    21. 27. When to start ARV? <ul><li>Proposed clinical definitions for initiating art </li></ul><ul><li>(in children under 13 years) </li></ul><ul><li>Stage 4: Treat urgently </li></ul><ul><li>Presumptive Stage 4 in <18 months: Treat urgently </li></ul><ul><li>Stage 3 : Consider treatment, CD4 if available will guide treatment decision (history of pulmonary TB or TB adenopathy </li></ul><ul><li>Stage 1 and 2 : Consider CD4 before initiating ARV </li></ul>
    22. 28. CD4 OMS <ul><li>0- 11 m: < 25%: 1500/mm3 </li></ul><ul><li>12- 3 years: < 20 %: 750/mm3 </li></ul><ul><li>3- 5 years: < 15 % : 350/mm3 </li></ul><ul><li>> 5 years: </li></ul><ul><ul><li>WHO Stage 4 irrespective of T CD4 cell count </li></ul></ul><ul><ul><li>WHO Stage 2,3 if CD4 < 350/mm3 </li></ul></ul><ul><ul><li>WHO stage 1 if CD4 < 200/mm3 </li></ul></ul>
    23. 29. Before to start: <ul><li>Exclude TB: Chest Rx +/- PPD for youg children (< 5 y) </li></ul><ul><li>Crofton SCORES </li></ul><ul><li>CD4 </li></ul><ul><li>Blood test : at least Hb ( FBC if avaible) </li></ul><ul><li>Lever fonctions and Hep B serology if necessary </li></ul><ul><li>Follow up: tests if necessary according to problems </li></ul><ul><li>Systematic: </li></ul><ul><li>Only CD4 / 6 months </li></ul>
    24. 30. What to start? <ul><li>ARV : 2 NRTI + 1 NNRTI </li></ul><ul><ul><li>D4T ou AZT + 3 TC + NVP/Effavirenz </li></ul></ul><ul><ul><li>D4T + 3TC + NVP: less expensive from far with generic </li></ul></ul><ul><li>AZT + 3TC + NVP if syrup (D4T syrup not avalable and should be kept in fridge) </li></ul><ul><li>PEDIMUNE to buy </li></ul>
    25. 31. ART IN FIXED DOSE COMBINATIONS: ADULT AND PAEDIATRIC FORMULATIONS Adult Tablet Junior Baby Adult Tablet Junior Baby d4T + 3TC + NVP &quot; Baby&quot; :: d4T 6mg, 3TC 30mg, NVP 50mg &quot;Junior&quot; d4T 12mg, 3TC 60mg, NVP 100 mg Adult : d4T (30 mg or 40mg), 3TC 150mg, NVP 200 mg) Children FORMULATIONS
    26. 32. Tuberculosis <ul><li>WHO: </li></ul><ul><li>≥ 3 years or ≥8 kg: 2 NRTI + Effavirenz </li></ul><ul><li>≤ 3 years and ≤8 kg: 3 NRTI or </li></ul><ul><li>2 NRTI + 2 X NVP </li></ul>
    27. 33. Tuberculosis treatment on children < 3 y and < 10 kg <ul><li>First line </li></ul><ul><li>< 8 kg : AZT or D4T + 3TC + Abacavir </li></ul><ul><li>Or AZT or D4T + 3TC + Dose Nevirapine X 30% </li></ul><ul><li>> 8 kg : AZT or D4T + 3 TC + Effavirenz </li></ul><ul><li>From 8 kg: Effavirenz (not recommanded < 10 kg) but Rifamipicine  20 % Effavirenz </li></ul><ul><li>If second line : Kaletra X 2 ? Or adapt with experts and age and TDM???? </li></ul>
    28. 34. <ul><li>Second line ARV treatment: </li></ul><ul><li>2 others NRTI ( ABC + DDI) + PI </li></ul>
    29. 35. Adherence <ul><li>Non ARV without adherence support and disclosure for children over 7 years old </li></ul><ul><li>Support groups…… </li></ul>