PAEDS HIV INFORMATION.pptx early diagnosis

Management and prevention of mtct

1. PAEDIATRIC HIV INFORMATION PRESENTED BY: MR. SIMUYEMBA ELVIS NURSE TUTOR ZERA INTERNATIONAL COLLEGEOF NURSING. HIV NURSE PRACTITIONER. NURSE EDUCATOR.

2. INTRODUCTION Zambia attained 90:90:90 USAIDS HIV/AIDS Epidemic Control Targets on December,02,2020 ( CDC 2,12,2020 Zambia attains 90:90:90 USAIDS HIV/AIDS Epidemic Control Targets ). By the year 2001 , Zambia had only approximately about 2000 people on Antiretroviral drugs (ARVs ) After meeting the 90:90:90 targets, Zambia decided to increase to targets to 95:95:95 in 2020 to be more aggressive in the fight against HIV/AIDS. Approximately 1,300,000 people are estimated to be living with HIV/AIDs in Zambia, 1,176,000 are on treatment and out of these 95% of those who are HIV positive know their status,out of these 94.6% are on treatment and out of these 94.2% are virally suppressed as of September 2020. (CDC 2,12,2020)

3. NEW HIV INFECTIONS IN ZAMBIA According to ZAMPHIA 2021 also showed important declines in annual HIV incidence from 0.61% in 2016 to 0.31% in 2021 corresponding to approximately 28,000 new HIV infections in 2021 compared to 43,000 in 2016.

4. DEFINE HIV HIV (human immunodeficiency virus) is a virus that attacks cells (CD4+) that help to fight body infections , making a person more vulnerable to other infection (OIS) and diseases . AIDS AIDS (acquired immunodeficiency syndrome) this is the late stage of HIV infection that occurs when the body`s immune system is badly damaged because of the virus.

5. CLASSIFICATION HIV Classification Group : Group VI ( ss RNA-RT) Family : Retroviridae Genus : Lentivirus Species : HIV-1 and HIV-2 Other lentiviruses include SIV, FIV, Visna and CAEV, which cause diseases in monkeys, cats, sheep and goats

6. HIV life cycle Stages of the life cycle Binding , Fusion & Entry 3.Reverse Transcription 4.Integration 5.Replication 6. assembly 7 .Budding

7. MODES OF TRANSMISSION OF HIV IN CHILDREN. 95% of infected infants get HIV through mother to child transmission (MTCT) 5% of infected children get infection through sexual transmission, infected transfused blood, scarification and other traditional practices

8. NATURAL HISTORY OF HIV IN CHILDREN The HIV virus progressively destroys CD4+ cells until immune deficiency develops. The natural disease course appears to follow three broad patterns in children- Category 1 (25 – 30%): Rapid progressors Rapid disease progression; infants die within 1 year Disease acquired in-utero or perinatally

9. Category 2 (50 – 60%): Slow progressors Children who develop symptoms early in life Deteriorate and die by 3 to 5 years Category 3 (5 – 25%): Long-term survivors Long-term survivors who live beyond 8 years of age

10. Factors related to disease progression are : 1. Size of infecting viral dose which is dependent on maternal disease status 2. The child’s immature immune system limits ability to contain the virus 3. Low infant CD4+ cell counts/percentages 4. Infants with high peak viral load have more rapid progression

11. FACTORS INFLUENCING TRANSMISSION RATES 1. STRONG EVIDENCE 1.High Viral Load 2.New infection (viral spike) 3.clinical Aids 4.Poor immune status (low Cd4 counts of less than 350 cells 5.Stds

12. LABOUR AND DELIVERY 1.prematurity 2.vaginal delivery 3. Prolonged rupture of membranes. 4.prolonged labour 5.instrumental deliveries

13. POSTNATAL 1.breastfeeding 2.duration of breastfeeding 3.mixed breastfeeding 4.mastitis 5.new infections

14. 2. WEAK EVIDENCE 1.viral strain 2.immune response 3.Nutritional status

15. EMTCT-PRONGS PRONGS 1(Refers to direct interventions to diagnose HIV infections in women and provide quality ARVs in order to decrease the risk of vertical transmission) Primary prevention of HIV among women of childbearing -use of condoms -Provision of PEP stands for post exposure prophylaxis meaning one is only eligible for PEP after been exposed to HIV and within 72 hours for 28 days.

16. Tenofovir disoproxil fumerate /lamivudine/ delutegravir (TDF 300Mmg/ETC300mg/DTG50mg) for 28 days (TLD) b. PREP stands for pre-exposure prophylaxis. This is given/taken before been exposed. In males it takes 7 days for it become effective and for females it takes 7 days and must be continued for as long as the risk is still there. TDF300mg/3TC300MG(Tenofovir disoproxil fumerate /lamivudine

17. NOTE: PREP DOES NOT PREVENT STDS,PREGNACES AND OTHER SEXUALLY TRANSMITTED INFECTIONS. -IEC of safer sex. Counselling Treatment of stds

18. PRONG 2 Prevention of unintended pregnancies among women living with HIV . - use of condoms. Use of family planning Sterilization for both male and female if child birth is complete

19. PRONG 3 Prevention of HIV from a woman living with HIV to her infant. Adherence counselling Initiation to ART Start septrine for all pregnant women. Viral load should be performed 4 weeks before delivery Promotion of safer sex

20. PRONG 4 Provision of appropriate treatment, care and support to women, children living with HIV and their families. Continue treatment and adherence counselling to the woman. Provision of family planning Refer all uninfected male partners in a serodiscondant relationship for circumcion .

21. DIAGNOSIS & STAGING OF PEDIATRIC HIV/AIDS. The definitive diagnosis of HIV infection in children at any age requires diagnostic testing that confirms the presence of HIV. Children ≥ 18 months: Antibody testing. Children < 18 months: Virologic testing.

22. LABORATORY DIAGNOSIS. Serological tests. detect antibodies to HIV proteins in blood and other body fluids. HIV ANTIBODY TESTS. determine SD Bioline Rapid. Self test kirt Saliva. Western blot.

23. Virologic tests. HIV DNA or RNA PCR (PCR= polymerase chain reaction). P24 antigen. Viral culture. NOTE: Currently we use DNA PCR testing in Zambia for early infant diagnosis. (NAT)

24. ANTIBODY TESTS (DIAGNOSIS).   Maternal HIV antibody passively transferred to infant across the placenta. Maternal antibody wanes with time ( 6-18 months). Antibody test is positive at birth in ALL children born to HIV infected women, including those children that are NOT infected. False positive results thus seen.

25. LABORATORY DIAGNOSIS: ANTIBODY TESTS Child ≥ 18 months: 2 or more antibody tests after 18 months confirm diagnosis. Child < 18 months. Positive antibody test may be a false positive result reflecting maternal antibodies. An alternative test therefore required to confirm the diagnosis A negative HIV antibody test in an exposed infant < 18 months suggests that the infant is HIV negative and should be confirmed at least 6-12 weeks after complete cessation of breast feeding.

26. Virologic tests . Virologic tests – detect HIV viral antigen in blood. They are the ideal method of HIV diagnosis in children < 18 months. HIV is diagnosed by one positive virological test. HIV is excluded by one negative virological tests at age >6 weeks, in a non-breastfed infant. If BF wait 6 weeks after cessation of BF. Both negative and positive virologic tests should be confirmed by a rapid test at age ≥ 18 months.

27. WHO STAGING IN CHILDREN CLINICAL STAGE 1 Asymptomatic Persistent generalized lymphadenopathy CLINICAL STAGE 2 Hepatosplenomegaly Papular pruritic eruptions Seborrhoeic dermatitis Extensive human papilloma virus infection Extensive molluscum contagiosum

28. Fungal nail infections Recurrent oral ulcerations Lineal gingival erythema (LGE) Angular cheilitis Parotid enlargement Herpes zoster Recurrent or chronic RTIs (otitis media, otorrhoea , sinusitis)

29. CLINICAL STAGE 3 Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations Moderate unexplained malnutrition not adequately responding to standard therapy Unexplained persistent diarrhoea (14 days or more ) Unexplained persistent fever (intermittent or constant, for longer than one month) Oral candidiasis (outside neonatal period ) Oral hairy leukoplakia

30. Acute necrotizing ulcerative gingivitis/periodontitis Pulmonary TB Severe recurrent presumed bacterial pneumonia Conditions where confirmatory diagnostic testing is necessary Chronic HIV-associated lung disease including brochiectasis Lymphoid interstitial pneumonitis (LIP) Unexplained anaemia (<80g/l), and or neutropenia (<1000/µl) and or thrombocytopenia (<50 000/µl) for more than one month

31. CLINICAL STAGE 4 Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia Recurrent severe presumed bacterial infections (e.g. empyema, pyomyositis , bone or joint infection, meningitis, but excluding pneumonia )

32. Chronic herpes simplex infection; ( orolabial or cutaneous of more than one month’s duration) Extrapulmonary Tuberculosis Kaposi’s sarcoma . Oesophageal candidiasis Central nervous system toxoplasmosis (outside the neonatal period) HIV encephalopathy

33. Conditions where confirmatory diagnostic testing is necessary CMV infection (CMV retinitis or infection of organs other than liver, spleen or lymph nodes; onset at age one month or more) Extrapulmonary cryptococcosis including meningitis Any disseminated endemic mycosis (e.g. extrapulmonary histoplasmosis , coccidiomycosis , penicilliosis ) Cryptosporidiosis

34. Isosporiasis Disseminated non-tuberculous mycobacteria infection Candida of trachea, bronchi or lungs Visceral herpes simplex infection Acquired HIV associated rectal fistula Cerebral or B cell non-Hodgkin lymphoma Progressive multifocal leukoencephalopathy (PML)

35. HIV-associated cardiomyopathy or HIV-associated nephropathy Herpes zoster Recurrent or chronic RTIs (otitis media, otorrhoea , sinusitis)

36. PREVENTIVE STRATEGIES

37. 1 . MALE CIRCUMCISION There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Three randomised controlled trials have shown that male circumcision provided by well-trained health professionals in properly equipped settings is safe. WHO/UNAIDS recommendations emphasise that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence. ( http://www.who.int/hiv/topics/malecircumcision/en/ )

38. 2. ABSTINENCE, BEING FAITHFUL AND CONDOM USE (ABC) The 3 ABCs of HIV transmission are: A bstinence, B eing Faithful, and C ondom Use . a. Abstinence and being faithful prevent the transmission of HIV through sexual contact.

39. ELIMINATION OF MOTHER TO CHILD TRANSMISSION OF HIV (EMTCT) This is also known as the prevention of mother to child transmission of HIV (PMTCT ) or the prevention of parent to child transmission of HIV ( PMTCT ). Mother-to-child transmission (MTCT) occurs when a HIV-infected woman passes the virus to her baby. This can happen during pregnancy, labour and delivery, or breastfeeding. Without treatment, around 15-30% of babies born to HIV-infected women will become infected with HIV during pregnancy and delivery. A further 5-20% will become infected through breastfeeding (De Cock et al, March 2000).

40.   COUNSELLING TESTING AND CARE (CTC) CTC is an effective intervention in HIV/AIDS prevention, care and mitigation. It is provided in both public and private sectors. It is provided both to those who are ill and those without symptoms, for example, men, women, children, rape victims and perpetrators. Zambia's target was to increase the number of people on ART by 24% from 2010 to 2015. In 2004, Zambia's National AIDS Council called for mandatory HIV/AIDS testing in all hospitals in an effort to control the epidemic. Their views provoked strong criticism from human rights activists and people living with HIV, who saw mandatory testing as a breach of human rights.

41. POST EXPOSURE PROPHYLAXIS (PEP) Early treatment of HIV-infected people with antiretroviral drugs protects 96% of partners from infection. Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV. Intravenous drug use is an important risk factor and harm reduction strategies such as needle-exchange programmes and opioid substitution therapy are effective in decreasing this risk.

42. PREVENTION STRATEGY OF POST EXPOSURE PROPHYLAXIS (PEP) PEP involves taking anti-HIV drugs as soon as possible after one is exposed to HIV to try to reduce the chance of becoming HIV positive. There are two types of PEP: Occupational PEP, (sometimes called " oPEP ") Non-occupational PEP, (sometimes called “ nPEP ”) Occupational exposure ( oPEP ) happens when someone working in a healthcare setting is potentially exposed to material infected with HIV. 

43. To be effective, PEP must begin within 72 hours of exposure , before the virus has time to rapidly replicate in the body. PEP consists of two to three antiretroviral medications and should be taken for 28 days. To be most effective, treatment should begin within an hour of infection. After 72 hours, PEP is much less effective, and may not be effective at all. Prophylactic treatment for HIV typically lasts four weeks. Non-occupational exposure ( nPEP ) happens when someone is potentially exposed to HIV outside the workplace (for example, condom breakage, sexual assault, etc.)

44. PRE-EXPOSURE PROPHYLAXIS (PREP) PrEP is short for Pre-Exposure Prophylaxis. It is aimed at preventing people who do not have HIV from acquiring it due to the stated exposure. PrEP has been shown to reduce the risk of HIV infection among adult men and women at very high risk for HIV infection through sex or injection accidents and injection drug use.

45. Pre-exposure prophylaxis (or PrEP ) is medicine taken to prevent getting HIV . PrEP is highly effective for preventing HIV when taken as prescribed. PrEP reduces the risk of getting HIV from sex by about 99%. PrEP reduces the risk of getting HIV from injection drug use by at least 74%. Pre-exposure prophylaxis with a daily dose of the drug Tenofovir with or without Emtricitabine is effective in a number of groups including the following situations:

46. CLINICAL COURSE OF HIV INFECTION IN CHILDREN Ideally, the diagnosis of HIV in children is made through perinatal testing. T he Center for Disease Control and Prevention (CDC) has issued guidelines for recommended testing and counseling for all pregnant women; however, many women, especially in developing countries and in poorer areas of developed world, do not have access to or do not avail themselves of the resources available.

47. Thus, for example, the diagnosis of HIV infection may follow an investigation of a prolonged or unsual presentation of an infection or a malignancy. Some studies suggest that children vertically infected with HIV become symptomatic from the neonatal period up to age 8 years and that 57% of this group have associated disease within the first year.

48. IMPACT OF AIDS ON CHILDREN AIDS impacts children in many ways as follows: Increased infant and childhood mortality Increase in number of orphaned children Increased deprivations in various forms; Mental Psychological School dropouts Abuse : Physical, Sexual

49. REFERENCE Avert . HIV and AIDS in Zambia AAVERT. (2017). Available online at https://www.avart.org/professionals/hiv-around-world/sub-saharan-africa/zambia (accessed march 19, 2020). Davis MA, et al. (2016). Survival of HIV-1 vertically infected children. Curr opin HIV/AIDS. (2016) 11:455-64.doi:10:1097/COH.00000000000000303. pubmed Abstract/ crossref full/text/ google scholar Mulenga A, et al. (2017). Determinants survival among HIV positive research article open access children on antiretroviral therapy in public hospitals, addis ababa , ethopia . Qual prim care . (2017) 25:235-41. Doi:10.1186/s12889-019-648201. UNAIDS. FACT SHEET- WORLD AIDS DAY 2019 GLOBAL HIV STATISTICS. UNAIDS (2019). UNICEF DATA (2018). Children, HIV and AIDS: the world today and in 2030. Available online at: https//data.unicef.org/resources/children-hiv-and-aids-2030/ (accessed march 19, 2020).