WHO technical recommendations on pediatric HIV care

1
WHO technical recommendations on pediatric HIV
care

• Summary of revised recommendations on
• diagnosis, clinical staging immunological
  classification, ART
• Dr Siobhan CROWLEY
• WHO, Geneva
• HIV Department

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Universal Access to comprehensive package of
prevention care

• CARE TREATMENT AND SUPPORT FOR ALL HIV EXPOSED
• Early diagnostic testing for HIV infection
• Infant feeding counselling and support
• Co-trimoxazole prophylaxis
• Assessment, management and follow up of common
  conditions
• Regular Growth monitoring, developmental
  assessment and support
• Immunization
• Prevention, screening and management of
  tuberculosis
• Prevention and treatment of malaria

Care and support for for uninfected
Early Diagnosis
Care and support where status still unconfirmed
Care for the infected child
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Public health programming for HIV Care

• Multiple entry delivery points
• PMTCT
• Hospital/U5Clinic/NRU - symptomatic patients
• Community facilities
• Home based care and outreach
• Linkages with preventive services inc HIV TC
• Family friendly care
• children primary care givers seen in same
  setting
• testing, support for siblings
• Chronic disease approach
• Clinical care teams
• Integrated care decentralized delivery
• links to facilities closer to community (HBC)
  task shifting

4
Life course approach

• Infants (lt 18 mo)
• Problem with confirming HIV diagnosis
• Rapid progression
• Less easy to use ARV formulations
• Children (18 mo 10 yr)
• Survivors
• Toxicities
• Long-term non-progressors
• Informing and disclosing
• Adolescents (gt 10 yr)
• Identity and self image
• Adherence
• Toxicities
• Informing disclosure to family, peers and
  partners
• Sexuality and fertility

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Co-trimoxazole

• New Guidelines
• Experts meeting May 2005
• Guidelines development group review April 2006
• Due for publication June 2006
• They address
• Adults and children
• Starting, discontinuation
• Toxicity and dosing

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Co-trimoxazole when to start
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Discontinuation of primary CTX prophylaxis
? However if Child gt 5 yrs started CTP during
infancy, d/c CTP can be considered where stable
on ART gt 12 mo CD4 gt used to initiate CTX
prophylaxis good adherence secure supply
access to ART C- IV restart if CD4 falls
below the initiation threshold or if new or
recurrent WHO 2, 3 or 4 conditions occur A- IV
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Discontinuation in the context of CTX adverse
reactions

• Severe adverse reactions to CTX in children
  uncommon
• (in the CHAP study, one child developed rash
  among 534 children randomized to CTX or placebo)
• CPT prophylaxis may need to be d/c in event of an
  adverse drug reaction.
• Insufficient data on CPT desensitization in
  children to make any recommendations on its use
  in resource limited settings.
• All starting CPT, their guardians and
  caregivers, need verbal or written information on
  potential adverse effects and advised to stop the
  drug and report to their nearest health facility
  if CTX-related adverse events are suspected.

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Discontinuation of secondary CTX prophylaxis

• Two options can be recommended
• Secondary prophylaxis should be administered
  lifelong.
  B-III
• Discontinuation of secondary CTX prophylaxis may
  be considered in children with immune recovery on
  ART based on the same CD4 criteria as for
  discontinuing primary prophylaxis. C-III
• (based on evidence that secondary CTX prophylaxis
  can be safely stopped in adults based CD4 cell
  count guided immune recover on ART)

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HIV Care ART for children guidelines
development process

• Diagnosis of HIV
• Working Draft prepared from TRG
• Experts review - April 2006
• Draft for public review end June 2006
• Assessment classification of HIV
• June 2004 expert meet
• Regional consultations Dec 2005-Oct 2005
• Global consensus meeting April 2006
• Now Final editing and layout publication
  imminent
• ART
• June 2005 -TRG expert meeting
• Public review Oct- Nov 2005
• Writing group review Nov 2005
• Now Final editing and layout publication
  imminent

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RECOMMENDATIONS - LABORATORY METHODS FOR EARLY
DIAGNOSIS OF HIV INFECTION

• Countries should strive to ensure access to
  virological testing (VT) for HIV is made
  available national wide A (I)
• Currently available HIV VT that can be considered
  include
• HIV PCR DNA A(I)
• HIV RNA A(I)
• U p24 B (III)
• Commercially available and in-house methods can
  be used provided their quality is validated,
  assured and documented.
• Dried blood spots (DBS) can facilitate
  decentralization of access to HIV VT. Currently
  procedures for use of DBS exist for the following
  VT assays
• HIV DNA A (I)
• HIV RNA A (II)
• HIV UP24 C (IV)
• More evidence to support these recommendations
  should become available and published shortly.

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RECOMMENDATIONS - VIRAL TESTING contd

• All the above HIV viral tests can be considered
  for use from 6 week of age irrespective of
  maternal ARV prophylaxis or ART DNA/RNA
  A(I)
• Time period for use of viral tests to provide
  reliable diagnosis after discontinuation of
  Breastfeeding is 6 weeks
  A (II)
• Single positive virological test at any age,
  should trigger clinical management as if HIV
  infected A
  (I)

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Presumptive diagnosis of severe HIV in HIV
exposed infant

• Seropositive Infant
• AIDS indicators condition
• Symptomatic with 2 or gt two or more of the
  following
• oral thrush
• severe pneumonia
• severe sepsis
• Other factors to support diagnosis of severe HIV
  include
• Recent HIV-related maternal death or
• Advanced HIV disease in the mother or
• No history of PMTCT intervention
• CD4 lt25
• Confirmation of the diagnosis of HIV infection
  should be sought as soon as possible.
• () As defined in IMCI

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Revised Staging Classification

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Immunological classification- all ages
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Mortality by WHO stage (from CHAP data courtesy
of Di Gibb)
1.00
STAGE 2
0.75
STAGE 3
0.50
Proportion surviving
STAGE 4
0.25
0.00
0
.5
1
1.5
2
2.5
Years from randomisation
Similar separation in all age groups, although
absolute mortality varies
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12-month mortality risk at selected thresholds
for CD4, CD4 count and TLC, by age
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CD4 Criteria for severe immunodeficiency
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TLC criteria of severe HIV immunodeficiency
(for use only in infants children with confirmed
HIV infection, clinical stage 2 CD4
measurement is not available)
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Recommendations for initiating ART in HIV
infected infants
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First Line ARV Drugs in children and young
adolescents
EFV
AZT or d4T
3TC or FTC
ABC
NVP
Triple NRTI alternative approach
Triple NRTI regimen can be considered where
NNRTI options are complicated (e.g. viral
hepatitis co-infection, TB co infection, pregnant
adolescents or if CD4 count gt 250 cells /mm3
severe reactions to NVP or EFV and HIV-2
infection).
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Second-line
Preferred first-line
ddI ABC PI/r

ZDV or d4T
NVP or EFV
3TC or FTC


ABC
NVP or EFV
3TC or FTC


ddI ZDV PI/r
Triple NRTI alternative
ZDV or d4T
ABC
3TC or FTC


NVP or EFV PI/r
3TC can be maintained in a second line regimen
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Simplified weight based dosing tables
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Further information

• crowleys_at_who.int
• Web page
• http//www.who.int/hiv/paediatric/en/index.html
• Scaling up antiretroviral therapy in
  resource-limited settings Treatment guidelines
  for a public health approach' are available at
  http//www.who.int/3by5/publications/documents/arv
  _guidelines/en/
• ARV Toolkit HIV Testing counselling toolkit
  on line
• All integrated management tools
• http//who.arvkit.net/tc/files/chronic_care_3_may_
  06.pdf
• Resources on HIV testing in children
• http//www.who.int/hiv/toolkit/arv/en/index.jsp
• http//www.who.arvkit.net/tc/en/content.jsp?dtc.1
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