National Guideline of Care

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National Guideline of CareTreatment of HIV
infection in children (Adaptation from the New
WHO guidelines August 2006)

• MUGABO S. Jules M.D
• TRAC/MOH
• November 21, 2006

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Transmission to child

• Mother to child gt 95
• Breastfeeding (also by other than mother)
• Transfusion
• Contaminated materials
• Sexuel
• Tattoos, scarifications, circumcision, dental
  extractions ...

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Mothers and child antibodies serology
Infected child
Non infected
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How to be sure of HIV infection on a child with
HIV serological test under 18 months ?

• Proviral HIV DNA or RNA (viral load) sensitivity
  and specificity nearly 100 after 6 weeks
  (expensive and unavailable in most limited
  ressources countries)
• Real time PCR DNA or RNA 10-15
• P24 heated and dissociated
• Dry Blood Spot Excellent solution- not too
  expensive

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PCR Sensitivity and specificity

• If only one (WHO accepts a dg on 1 PCR)
• At 6 weeks for formula feeding
• Anytime if symptoms (or control serology first if
  older than 9 months old)
• PCR at 5 months to decide stopping breastfeeding
• If asymptomatic one month after weaning (control
  first for serology before PCR if gt 9 m )
• DBS prefered but if not available blood test
  with 2 ML EDTA tube to do PCR

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Biological signs without PCR

• Serology first from 9 months if mother is HIV
  before doing any PCR
• If Do PCR if possible - Continue SMX / TMP
  and control serology at 18 months
• If and no breastfeeding since 3 mois Stop
  SMX/TMP sure child is not infected

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New WHO recommandations (December 2004- update
aug 2006)

• Clinical diagnosis for children under 18 months
  with positive HIV serological test
• 2 clinical signs
• 1) Sepsis (nessitating IV treatment )
• 2) Severe pneumonia (nessitating 02)
• 3) Oral Candidosis
• Or
• AIDS related signs wasting syndrom, PJP,
  kaposi, Toxo, encephalopathy, extra pulmonary TB
  

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Without PCR very bad specificity and sensitivity

• Children exposed to HIV are also very exposed to
  TBC with HIV parents
• The most confonding disease TUBERCULOSIS
  TBalso have pneumomnia and malnutrition with
  oral thrush and low CD4 very difficult to
  diagnose in children ( BK rarely )
• We can still improve sensibility and specificity
  of these criterias - Important to continue
  collecting clinical signs /CD4 and compare to
  gold standard (PCR)

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PCR is very important but shouldnt be an excuse
not to give ARV

• IF presomptive clinical signs of Aids with a
  child having a positive serological HIV test
  before 18 months.
• Decision
• Food supplementation, Cotrimoxazole, TB treatment
  and if no improving after 3 weeks ARV on
  presomptive signs if PCR not possible
• No gold standard and no possibility to do
  clinically a difference between disseminated TB
  and HIV
• Always control HIV serology if child reach 18
  months

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New WHO recommendationsDecember 2004 and revised
in aug 2006

• Stadifications similar to adult (4 stages)
• Consider CD4 and Total Lymphocytes

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Stage 2

• Hepatosplenomegaly
• Recurrent or chronic upper respiratory tract
  infections
• Parotid enlargement
• Lineal Gingival Erythema (LGE)
• Angular chelitis
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Extensive Human papilloma virus infection or
  Molluscum infection
• Herpes zoster
• Fungal nail infections

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Stage 3

• Conditions where a presumptive diagnosis can be
  made using clinical signs or simple
  investigations
• Unexplained moderate malnutrition not adequately
  responding to standard therapy
• Unexplained persistent diarrhoea (more than 14
  days)
• Unexplained persistent fever (intermittent or
  constant, for longer than 1month)
• Oral candidiasis (outside neonatal period )
• Oral hairy leukoplakia
• Acute necrotizing ulcerative gingivitis/peridontit
  is
• Pulmonary tuberculosis
• Severe recurrent presumed bacterial pneumonia (2
  or more episodes in 6 months)

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Stage 3

• Lymphoid interstitial pneumonitis (LIP) Chest X
  ray
• Full haematologic test Unexplained Anemia
  (lt8gm/dl), neutropenia (lt1,000/mm3) or
  thrombocytopenia (lt30,000/ mm3) for more than 1
  month
• Chronic HIV associated lung disease including
  brochiectasis

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Stage 4

• Unexplained severe wasting or severe malnutrition
  not adequately responding to standard therapy
• Pneumocystis pneumonia
• Recurrent severe presumed bacterial infections
  (2 or gt episodes within one year e.g. empyema,
  pyomyositis, bone or joint infection, meningitis,
  but excluding pneumonia )
• Chronic orolabial or cutaneous Herpes simplex
  infection (of more 1 month duration)
• Extrapulmonary tuberculosis
• Kaposi's sarcoma
• Oesophageal Candidosis
• CNS Toxoplasmosis
• HIV encephalopathy

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Without ARV-Many things to help

• Social and psychological support
• Exclude TB
• Do surch for TB actively asking systematic
  questions Chronic cough and fever
• Prophylaxy cotrimoxazole
• Nutrition

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TB is very difficult to diagnose on HIV children
(Pulmonary and disseminated TB)

• Gastric lavage often negative (10 only )
• PDD often negative because of immuno suppression
• Scores ( Crofton) guidelines PNILT but not
  very good specificity and sensitivity
• Chest X-ray not always significative and often
  very bad quality
• Abdominal ultrasound need trained doctors and
  materials but can help for diagnosis

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NEW WHO - April2006
ANTHTROPOMETRIE
Le Poids
La Taille
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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
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Prophylaxy

• Pneumocystis - Toxoplasmosis- Infections
• CMX prophylaxy for all
• Exposed children SMX/TMP 25 mg/5 mg /kg OD
  from 6 W until HIV infection is excluded (PCR or
  serology)
• HIV infected children lt 5years
• HIV infected children gt 5 years Consider WHO
  clinical stage or CD4 before initiating CMX
  prophylaxy ( WHO stage 2,3 and 4 or CD4 lt 350/ul)
• If allergy on CMX
• Desensibilisation
• Dapsone 2 mg/kg if necessary (but expensive)
• 
  
  

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When to start ARV?

• Proposed clinical definitions for initiating art
• (in children under 13 years)
• Stage 4 Treat urgently
• Presumptive Stage 4 in lt18 months Treat urgently
• Stage 3 Consider treatment, CD4 if available
  will guide treatment decision (history of
  pulmonary TB or TB adenopathy
• Stage 1 and 2 Consider CD4 before initiating
  ARV
• 
  

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CD4 OMS

• 0- 11 m lt 25 1500/mm3
• 12- 3 years lt 20 750/mm3
• 3- 5 years lt 15 350/mm3
• gt 5 years
• WHO Stage 4 irrespective of T CD4 cell count
• WHO Stage 2,3 if CD4 lt 350/mm3
• WHO stage 1 if CD4 lt 200/mm3

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Before to start

• Exclude TB Chest Rx /- PPD for youg children
  (lt 5 y)
• Crofton SCORES
• CD4
• Blood test at least Hb ( FBC if avaible)
• Lever fonctions and Hep B serology if necessary
• Follow up tests if necessary according to
  problems
• Systematic
• Only CD4 / 6 months

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What to start?

• ARV 2 NRTI 1 NNRTI
• D4T ou AZT 3 TC NVP/Effavirenz
• D4T 3TC NVP less expensive from far with
  generic
• AZT 3TC NVP if syrup (D4T syrup not avalable
  and should be kept in fridge)
• PEDIMUNE to buy

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ART IN FIXED DOSE COMBINATIONS ADULT AND
PAEDIATRIC FORMULATIONS
d4T 3TC NVP
Adult Tablet
Junior Baby
FORMULATIONS
Adult d4T (30 mg or 40mg), 3TC 150mg, NVP
200 mg)
"Junior" d4T 12mg, 3TC 60mg, NVP 100 mg
Children
Adult Tablet
Junior Baby
"Baby" d4T 6mg, 3TC 30mg, NVP 50mg
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Tuberculosis

• WHO
• 3 years or 8 kg 2 NRTI Effavirenz
• 3 years and 8 kg 3 NRTI or
• 2 NRTI 2 X NVP

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Tuberculosis treatment on children lt 3 y and lt 10
kg

• First line
• lt 8 kg AZT or D4T 3TC Abacavir
• Or AZT or D4T 3TC Dose Nevirapine X 30
• gt 8 kg AZT or D4T 3 TC Effavirenz
• From 8 kg Effavirenz (not recommanded lt 10 kg)
  but Rifamipicine ? 20 Effavirenz
• If second line Kaletra X 2 ? Or adapt with
  experts and age and TDM????

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• Second line ARV treatment
• 2 others NRTI ( ABC DDI) PI

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Adherence

• Non ARV without adherence support and disclosure
  for children over 7 years old
• Support groups