Children infected with and affected by HIV

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Children infected with and affected by HIV
Issues Concerns, Global perspectives
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(No Transcript)
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Children with HIV

• By the end of 2005, 2.3 million are children
  under age 15.
• In 2005, 700,000 children under the age of 15
  were newly infected.
• Every day, more 1,900 children become infected
  with HIV,

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AIDS

• More than 500,000 children died of AIDS-related
  illnesses in 2005
• In Asia, an estimated 180 000 75 000390 000
  children living with HIV.
• Poor access to ART has resulted in estimated
  380,000 children dying annually from AIDS-related
  illnesses

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PROPORTION OF CHILDREN

• 5.7 HIV infection (2.3 out of 40.3 million)
• 18 of all AIDS deaths worldwide

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What does it show ?

• Unfavorably skewed
• ART access,
• Treatment and
• Care services
• leaving children out

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What does it do?

• Reverses the efforts to reduce IMR and U5MR (
  in some of the African countries, it has doubled
  IMR)
• India already accounts for the worlds ¼ IMR
• Burdens the health infrastructure and services

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Why ?

• Caught in the vicious cycle are children, born
  HIV positive, punished for no fault of theirs.
• Freedom Foundation

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Access to ART

• 1 out of 5 ( Global)
• 1 out of 6( Asia)
• 1 out of 10 ( Children, globally)
• Overall HIV population Less than 1 out of ten
  (India )
• Children in India (No clear figures)

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Children with HIV/AIDS in India

• Sentinel surveillance estimates
• 2003 0.50(55,145) (1.08)
• 2004 0.60 (1.11)
• 2005 0.60 or 59,007 (1.2)
• 2006 0.09 million (3.8)

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Why children need focus

• HIV Progresses faster in children than adults(
  Ethiopia Median life expectancy after HIV
  infection
• 9 years (adults)
• 3 years (children)
• The impact is more severe and harsh for
  children
• Children are most neglected, invisible and
  voiceless group

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• Do we show them
• the Light of Life
• or
• Darkness of Doom

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Barriers in Diagnosing

• Large number of Home deliveries without
  complete and comprehensive ANC
• Mothers antibody till 18months , which delays
  diagnosis and prophylaxis
• Before 18 months - PCR Test ( Polymerase Chain
  reaction)
• Cost
• Trained manpower
• Logistics ( freezing)

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Treatment Barriers

• Cost
• Lack of child friendly formulations
• Palatability
• Taste
• Crushability
• Complicated regimens ( frequency , number and
  type of tablets, measurement, storage,
• Interfering with schools schedules

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Lack of social support

• Lack of parents, or ill parents dealing with
  repeated opportunistic infections
• Stigma and discrimination
• Insensitive school environment
• Inadequate health services

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Adherence barriers

• Adherence rates exceeding 95 are desirable to
  maximize the benefits of ART.
• Structural barriers- distance, cost, availability
  
• Personal barriers- formulations, doses and
  inability to swallow
• Need for adjustment of doses according to
  growth.

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Some successful experiences_MTCT Plus

• Care and treatment of HIV-exposed/ infected
  children integrated into family-focused
  programmes Early infant diagnosis (Edx)
• PCP prophylaxis
• CD4 monitoring
• Antiretroviral therapy (ART)
• TB diagnosis and management
• Adherence
• Psychosocial support

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Results

• 1,276 infants children enrolled Apr,04.
• 1183 (93) babies of most recent pregnancy
• Mean age at enrollment is 5 months
• 57 EXP are infants
• 82 (6) are INF siblings and 11 (1) are INF
  children living in the household
• 596 receiving co-trimoxazole for PCP prophylaxis

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Unite for Children, Unite against AIDS

• Aims to ensure that
• adolescents children are included in HIV/AIDS
  strategies become central focus.
• ART or antibiotic prophylaxis, or both, reaches
  80 of children in need by 2010

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By providing child-focused framework for
National programmes around 4 Ps

• Prevent infection among adolescents and young
  people
• Prevent mother-to-child transmission of HIV
• Provide pediatric treatment and
• Protect and support children affected by HIV/AIDS.

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Supporting Public-private partnership for
Pediatric HIV

• Innovator pharmaceutical companies for new/
  improved pediatric formulations
• Generic pharmaceutical companies for manufacture
  of pediatric ARVs
• Expediting regulatory review of new pediatric
  ARVs and supporting programs to address
  structural barriers to ART
• Multilateral organizations such as UNAIDS and
  UNICEF, to provide their expertise

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PEPFAR President Bushs Emergency Plan for AIDS
Relief

• Difficulties in diagnosing HIV infection in
  infants.
• Health care infrastructure and personnel
  limitations.
• Limited information about pediatric dosing
  requirements at different ages.
• Regulatory requirements.
• Fewer formulations for pediatric ARV.

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Important issues around testing

• Consent
• Counseling
• Special groups
• Disclosure
• Confidentiality
• Phasing of ART dosing in adolescents

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Consent to testing

• Age of consent ( When)
• Authority to consent (Who)
• Process ( How)
• Setting for consent ( Where)
• Intentions for consent ( Why)

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Age of consent

• Capacity to consent to HIV test is determined
  without regard to age. NIH
• Children YP less than 16 yrs can give consent
  if they are Gullick competent i.e have
  sufficient understanding of the implications of
  test CHIVA
• Informed consent to testing and treatment can
  be provided by child of the age 14 years and has
  sufficient maturity to understand the benefits,
  risks, social and other implications-SA

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VCT- UGANDA

• VCT should be at which he understands-
• considered 12 yrs
• Parents to be fully involved for children below
  12 yrs
• Right to dissent also 12 years
• Legal age of consent 18 yrs
• Between 12-18 child should consent but with
  approval of parents

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Age to consent--contd

• Informed consent for HIV testing of minors
• However, the informed consent of parents /
  guardians is required prior to testing of minors(
  Legal Minors ?) for HIV- INDIA
• Counseling and testing of children below 16 years
  of age shall be carried out only when the
  Counsellor has determined and is satisfied that
  it is in the best interest of the child and not
  otherwise and should involve parents and
  guardians- TANZANIA .

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Canada

• Informed consent to testing in every
  circumstance
• informed consent to HIV testing to be recorded in
  writing.
• Performing HIV testing without informed consent,
  or pressuring or coercing patients into testing,
  is unethical, could give rise to civil or
  criminal liability, and could carry disciplinary
  sanctions

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Authority to consent - Who

• By parent or legal guardian
• Manager of childrens home of the child is
  legally placed SOUTH AFRICA
• Minors are encouraged to involve their
  parents/guardians in supervising their health
  care. However, unwillingness to inform
  parents/guardians should not interfere with the
  minors access to information and services.
  INDIA

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Tanzania and Uganda

• Counseling and testing of children below 16 years
  of age shall be carried out only when the
  Counselor has determined and is satisfied that it
  is in the best interest of the child and not
  otherwise and should involve parents and
  guardians_ TANZANIA
• Parents may consent for legal minors but
  counselor to assess whether it is in best
  interest of child- UGANDA

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CANADA

• For Children who do not have such capacity,
  parents or court can give consent . Best to
  involve both parents
• Young People Over 16 can consent to their
  own medical treatment ( Family reform act 1969)
  and parent can not override the consent for
  treatment, but they ( Parents Or Court )can
  override the refusal to treatment in the
  interest to child.

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NIH ( America)

• In intact families, the biological parents
  generally have the legal authority to consent.
• Infants and Very Young Children do not have the
  capacity to consent because they do not yet have
  the ability to understand or make informed
  decisions.
• The person authorized pursuant to law has the
  right to decide whether the child may be tested
  and to consent on behalf of the child.

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• Counseling with or without testing, can and
  should be tailored to the needs of particular
  client groups, some of which have very different
  needs. These groups include Children.-WHO
• Administering ART is never a emergency . it
  should always begin with detailed discussion
  with the child, family and caregivers -ICAP

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Mildmay Center in Uganda

• Guidelines for HIV Testing in Children and
  Counseling about Issues Related to HIV Testing
• How to deal with a child who is brought for HIV
  testing
• Creating opportunities for effective
  communication with children
• HIV/AIDS counseling and testing in children
• Communication and counseling with children Key
  principles
• Answering difficult questions

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South Africa

• A child must receive age appropriate pre and
  post test counseling by a trained person,
  regardless of whether the child is able to
  provide consent as per childrens act.
• Ensure confidentiality
• Ask questions in a sensitive manner about
  current and previous risk behavior

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Special groups

• Abandoned infants
• Orphaned children
• Institutional children / Custodial children/
  Foster care
• Child abuse cases/ Rape cases( in and out of
  family )
• Street Children
• Mentally ill children
• Mature minor/ Emancipated minors/ married minors
  

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Special group

• In case of for children who do not have parent
  or, have been sexually abused head of health
  centre, institution, hospital or responsible
  person to consent- CANADA
• In accordance with the Mental Health Act no. 18
  of 1973 certain designated persons may consent to
  the medical treatment undertaken on a mentally
  ill person. ZAMBIA

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Tanzania

• Emancipated minors, i.e. those who are married,
  pregnant or those that could engage in behavior
  that puts them at risk or are sexually active
  should be considered as mature minors who can
  participate in the dialogue in the VCT process.
• A guardian consent form for testing a minor or
  client with communication disability must be
  filled before testing is done

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NIH

• Foster Care. Consent to be obtained from the
  child's biological parents, if possible, and/or
  from the local Social Services Commissioner
  responsible for overseeing foster care placements
  only if the foster care child does not have the
  capacity to consent to an HIV test,The
  Administration for Children's Services has this
  responsibility. Neither the foster parents nor
  the foster care agency can legally give consent
  for an HIV test for a foster child.
• Adopted Children The adoptive parents assume all
  parental rights therefore they, not the
  biological parents, have legal authority to
  consent to health care for and HIV testing.

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NIH- CONTD

• Married Minors and Minor Parents Have the Right
  to Give Consent
• Pregnant Minors may give effective consent for
  "medical, dental, health and hospital services
  relating to prenatal care." Therefore, a pregnant
  minor generally has the ability to provide
  consent for her own HIV test.

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Transition of ART In Adolescents

• Challenges for ART in adolescents
• VCT UGANDA
• Growing phase
• Changing lifestyle
• Changing self esteem
• Peer pressure
• Educational needs / school

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NIH- Adolescents

• Dosages of medications for HIV infection and
  opportunistic infections should be prescribed
  according to Tanner staging of puberty not on
  the basis of age
• Adolescents in early puberty (i.e., Tanner Stage
  I and II) shd be administered doses using
  pediatric schedules, those in late puberty (i.e.,
  Tanner Stage V) should follow adult dosing
  schedules.

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NIH_ contd

• Adult GL for ART is suggested for post pubertal
  adolescents because who were infected sexually
  or through IDU follow a clinical course that is
  more like adults than children
• HIV-infected adolescents who are long-term
  survivors of HIV infection acquired perinatally
  or through blood products as young children have
  clinical course that differs from that of former
  group

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NEPAL

• Adolescent lt 13 years should receive ART dose
  based on pediatric guidelines. Adolescents gt 13
  years should receive ART dose based on adult
  guidelines according to weight. -

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ICAP

• For clinical staging and determining eligibility
  for ART, Adult GL be used for 13children
• Dosing of medication be determined by physical
  maturity rather than age. Pediatric GL until
  Tanner V stage is reached from where adult GL
  can take over

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CHIVA

• Guide titled Growing up, gaining independence
  Principles for transition of HIV care It
  discusses dealing with stigma, starting the
  process, increasing knowledge and autonomy for
  the young person.

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Care and support

• Immunization
• Nutrition support
• Counseling and dealing with stigma
• Palliative care
• Care of terminal end

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• Immunization

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Immunization

• SOUTH AFRICA
• Routine immunization for HIV infected and
  exposed
• BCG can be given routinely at birth
• HIV VE to receive all vaccines including live
  vaccines

• NAMIBIA
• All vaccinations to be given according to the
  regular vaccination plan.
• In addition Hepatitis B vaccine should be given
  to all children of HIV ve mothers at birth, 6
  weeks and 14 weeks simultaneously with BCG, DPT1
  and DPT3.

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Immunization( EIP_WHO)

• BCG can be safely given to asymptomatic children.
  
• OPV, DPT and measles should be administered as in
  normal children.
• Hepatitis B, pneumococcal vaccines and H.
  influenza vaccines are also recommended. Yearly
  influenza vaccines in children beyond 6 months of
  age may be administered if available

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Hong Kong

• Hiv exposed and infected infants and children
  should receive all standard immunization with
  few exceptions
• IPV should replace OPV 7 should start in 2-4
  months
• MMR only if child is not CDC immune Category
  3
• BCG is recommended to all infant born to HIV
  Mothers
• HIB AT 2 months and 4 months
• Influenza vaccine at 6 months and annually
• Polysaccharide pneumococcal at 2year and
  booster dose after 6 months

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• NIH

• ICAP

• Most vaccines are routinely given to HIV
  children and few complications have been reported
  .
• ICAP children are given immunization according
  to local/ country guidelines

• No child with HIV or anyone in the household
  should ever take oral polio vaccine.

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CHIVA

• Routine immunization
• Diphtheria, Tetanus, Pertusis, Polio, Hib, and
  Meningococcal C, Measles, Mumps, Rubella
• Exceptions
• No BCG
• No MMR ( CDlt!5)
• Polio only IPV
• Yellow fever- no evidence

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• Nutrition support

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WHO Technical Advisory group on Nutrition
and HIV 2003)

• Nutrient requirements for HIV ve (not child
  specific)
• Energy need increased by 10 asymptomatic stage
  and 20-30 in symptomatic HIV
• Protein No evidence of additional need
• Multiple Micronutrient Supplements Best achieved
  through adequate diet. Where intakes cannot be
  achieved, micronutrient supplements may be needed
  (at RDA levels).
• Evidence show that high dose of some
  micronutrient supplements eg. Vit. A, Zinc and
  Iron can produce adverse outcomes in PLHA

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Hong Kong

• Energy needs of HIV infected children are 75-150
  protein needs are 100-150 of the normal
  required to support immune system avoid
  wasting
• All HIV infected infants children should
  receive a baseline nutritional assessment
  within 3 months and follow up every 1-6 months
  depending on the child status

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ICAP MAILMAN

• All children in ICAP programmes receive
  multivitamins and nutrition counseling/
• Discusses in detail about the nutritional
  assessment, measurement and reasons of growth
  failure , feeding options and the need for
  informed choice

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South Africa

• Nutrition counseling and demonstration
  guidelines for dealing with feeding problems
• Apart from general programme of INP AS PER
  IMNCI, food supplement Philani and philani with
  Zymune is distributed to all ART service points

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ZAMIBIA Nutrition Guidelines for care and
support of PLWHA

• Has a separate 113 page document and section on
  VE Children deals with
• Nutrition assessment
• Nutrition counseling (0-6 months and 6-36
  months )
• Nutrition education
• Monitoring growth and development
• Recommends Biannual supplementation of vit A
  and daily multivitamin supplement if available

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Tanzania

• Nutritional needs of children are high in HIVve
  children the because of recurrent infections.
  Hence they should take higher amount of energy
  and body building foods per meal to help maintain
  lean body weight.
• Qualitatively, the nutritional needs of HIV
  positive children are similar to the needs of HIV
  -ve children. Most of these children should feed
  on three meals per day with two snack in between
  the meals.
• All children should receive Vitamin A
  supplementation where possible.
• When ill, should receive nutritional support and
  care and counseling

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Palliative care and Care of terminal child
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Lack of social support

• Lack of parents, or
• Ill parents dealing with repeated
  opportunistic infections
• Stigma and discrimination
• Insensitive school environment
• Inadequate health services

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South Africa

• Palliative care is no longer defined as care for
  those in whom cure is not possible. It is being
  promoted in South Africa as The active,
  comprehensive care for the physical, emotional
  and psychosocial needs of the child and the
  family.
• Recommendations for pain control in children
• Establish the cause of the pain.
• Effectively manage the underlying condition.
• Use pain scales to assess
• Involve the parent/caregiver when assessing
  whether
• pain is present. If in doubt, treat the child and
  observe the response.

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South Africa Pediatric pain scales

• FLACC( For under 3) (F) Face (L) Legs (A)
  Activity (C) Cry (C) Consolability is scored from
  02, which results in a total score between 0 and
  10.
• Numeric pain scale 3-6yrs
• Color pain scale 3-6 yrs
• Word graphic scale for 6 yrs

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Analgesic ladder

• Step 1- For mild pain
• Paracetamol, oral, 46 hourly, when required to a
  maximum of four doses daily, syrup 5 ml/8 kg (In
  between dose for in between wts)
• Step2- For moderate pain
• Add codeine phosphate syrup to Step 1.
• Step 3 for severe pain
• Paracetamol or ibuprofen can be used with
  morphine in Step 3.
• Morphine is doctor initiated.

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CARE OF THE TERMINAL CHILD

• General management
• Relieving distress in the child
• Treating easily manageable complications
• Limiting hospital admissions
• Reducing the duration of hospital stay
• Parents/caregivers are adequately counseled,
• Provide emotional support to a dying child and
  the grieving family.
• Supportive care
• Indication for Inpatient care
• Home based care