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Children & HIV

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Joel Stegen

on 15 March 2013

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Transcript of Children & HIV

Children and HIV/AIDS Americas 63,000 Europe 13,000 Eastern
Mediterranean 33,000 Western Pacific 36,000 South-East Asia 140,000 Africa 3,100,000 5000 New / 3600 Deaths 2400 New /1300 Deaths 7400 New / 4100 Deaths 17,000 New / 12,000 Deaths 5000 New / 2700 Deaths 350,000 New / 260,000 Deaths
Joel Stegen
Terrence Messmer
David Collins
Zena Aladdin Pediatric HIV (<14 years old)
3.3 Million Living with HIV
330,000 New Infections in 2011
230,000 Deaths in 2011
(World Health Organization, UNAIDS, Unicef, 2011)
91% of HIV infected children in sub-Saharan Africa
Most of these from Vertical Transmission
Untreated HIV+ mothers have up to 45% chance of infecting children
~30% of births result in infection
Another 15% infected during breast feeding
(World Health Organization, 2008) Children and HIV Rate of Transmission Dependent on Disease Progression in Mother Prenatal Antiretroviral Prophylaxis drastically reduces risk of mother to child transmission
Developing countries has achieved rates lower than 5%
Rates in the US and other developed countries are less than 1% with HAART
(Centers for Disease Control and Prevention, 2012) Treatment is Highly Effective The Following Statistics are from the end of 2010.... Neonatal Testing
Antibody tests invalid first 6 months of life
Infant has mother’s antibodies
Nucleic acid testing or HIV isolation (viral culture) only options in infant <1 month old
HIV p24 antigen test can be used when >1 month old
Result is considered “Presumptive HIV Infection” until 2nd confirmatory test is done at a later date
Cannot conclusively determine infant is uninfected until 4 weeks of age
(Centers for Disease Control and Prevention, 2013) Clinical Issues - Diagnosis Changes to Infant Treatment Guidelines
South African study (2006-2012) Children with HIV Early Antiretrovirals (CHER)
Better long term outcomes if early (mean 20 weeks of age) vs. deferred ART
Previously, only severe clinical disease was treated before 1 year of age
Established safety and effectiveness of early treatment with interruptions after 1st year.
(Cotton, et al., 2012) Clinical Issues - Treatment Frequent and severe bacterial infections
Otitis Media / Sinusitis / Pneumonia
Viral and Fungal OI’s similar to those seen in adults
Deterioration is often more rapid than in adults
Growth Failure / Failure to Thrive / Wasting
Developmental Issues
Linked to HIV Encephalopathy
HIV Viral Proteins are Neurotoxic
Viremia (not opportunistic infection) causes white matter degeneration and brain atrophy
Failure to attain typical milestones
Developmental delay / Learning deficits
Impaired development of expressive language
Behavioral Abnormalities / Attention Deficits / Memory Deficits
(Greenfield & Steele, 2013) Pediatric Medical Presentation More than 90% of children who acquired HIV in 2011 live in this region (directly proportional to the number of infected of HIV+ pregnant women)
Variance of Current Region
Outcomes HIV in children of Sub-Saharan Africa As an overall region, between 2009-2011 number of children newly infected with HIV in Sub-Saharan Africa fell by 24%
20 of the countries reported decline of 20-59%
11 countries reported decline of only 1-19%
4 countries reported an increase
Why these variances?
Amount of money countries invest in prevention programs
Accessibility/inaccessibility of medical treatment
(Rodney, 2010) HIV in children of Sub-Saharan Africa (Domek, 2006) Mental: emotionally dealing with the stigmatism that still exists in the culture
Socially: HIV-positive children who receive ART are surviving longer therefore are continuing on getting an education
Economical: those HIV+ children mainly come from poverty stricken families, and the costly treatment further adds to their financial burden Mental, Social and Economical Impact on HIV+ Children in Low-Middle Income Sub-Saharan Africa There is a population of 19.8 million people under the age of 18,
And 6.6 million people under the age of 5 as of 2010.
Number of children aged 0-14 estimated to be HIV+ is 180 thousand as of 2009.
And 2.9% of total young people are estimated to be HIV+
Young people made up 23% of the total population in Kenya as of 2010.
Orphans aged 0-17 number approximately 2.6 million as of 2009
Almost half, approximately 1.2 million are due to HIV/AIDS.
(UNICEF, 2013) A Closer Look - Kenya Nyumbani “Nyumbani works on behalf of children suffering from the HIV/AIDS crisis, and is a leader in responses that capitalize on sustainability and income-generating relief.”
An American Jesuit priest, Father Angelo D'Agostino, MD founded Nyumbani in 1992. It was the first facility in Kenya for HIV-positive children.
Located outside of Kenya’s capital, Nairobi. Means “home" in Swahili.
Home to 119 children ranging in age from 16 months to 24 years from all over Kenya and areas within and around Nairobi.
Opened a state-of-the-art diagnostic laboratory in 1998 with capabilities for Antiretroviral Therapy, HIV Testing, Hematology, Microbiology, Serology, Clinical Chemistry and anti-retroviral Genetic Analyzer. Included addition of BSL 3 facility in 2010.
In 2005 built a bio-friendly village designed for those who’ve lost family members to HIV/AIDS.
(Nyumbani, 2013) Nyumbani Nyumbani Court Allows Kenyan Pupils with HIV into Schools
The president of Kenya at the time, Mwai Kibaki, pledged free primary-school education during his campaign for the presidency and spoke out against discrimination against Kenyans with HIV.
Father Angelo D'Agostino sued the government of Kenya because 72 HIV+ children from Nyumbani were turned away when they tried to attend public school.
Judge ruled in favor of orphans in January 2004, guaranteeing that the children are allowed to attend government schools.
(Lacey, 2004) (Rourke, 2006) Confronting Stigma Nyumbani Improved access to HAART
2001 WHO Doha Declaration on the Agreement on Trade-Related Aspects in Intellectual Property Rights and Public Health.
Patent rules should be interpreted and implemented to protect public health and promote access to medicines for all.
Created certain loopholes for poor countries with critical HIV levels
Resulted in contracts to purchase HIV meds from Indian generic manufacturing plants
Some African plants being built
Cost per patient per year before 2001 Declaration: $10,000 to $15,000
Cost per patient per year after 2001 Declaration: $143 for first line therapy, $442 for second-line and $2766 for third line.
(Joint United Nations Programme on HIV/AIDS (UNAIDS), 2011)
(Hoel, Berger, Calmy, & Moon, 2011) Looking Ahead United Nations General Assembly – 2011
Adopted ambitious targets and a strategy to “Get to Zero” in regard to vertical transmission
Made possible by more affordable drugs.
Improvements being made, but there is still much to do
(Kuhn, et al., 2010) A New Global Plan Large Disparities Still Exist Hoel, E., Berger, J., Calmy, A., & Moon, S. (2011). Driving a decade of change: HIV/AIDS, patents and access to medicines for all. Journal of the International AIDS Society, 14(15).
Joint United Nations Programme on HIV/AIDS (UNAIDS). (2011). DOHA+10-Trips Flexibilities and Acces to Antiretroviral therapy: Lessons from the past, opportunities for the future. UNAIDS.
Kuhn, L., Aldrovandi, G., Sinkala, M., Kankasa, C., Mwiya, M., & Thea, D. (2010, June 1). Potential Impact of New WHO Criteria for Antiretroviral Treatment for Prevention of Mother-to-Child Transmission. AIDS, 24(9), 1374-7.
Lacey, M. (2004, January 10). Court Allows Kenyan Pupils with HIV Into Schools. New York Times.
Nyumbani. (2013, March 13). About Us. Retrieved from Nyumbani: www.nyumbani.org
Persaud, D., Gay, H., Ziemniak, C., Chen, Y., Piatak, M., Chun, T.-W., . . . Luzuriaga, K. (March 2013). Functional HIV Cure after Very Early ART of an Infected Infant. Session 10 - Oral Abstracts: Is There Hope for HIV Eradication? Atlanta, GA: 20th Conference on Retroviruses and Opportunistic Infections.
Rodney, P. N. (2010). Addressing the impact of HIV/AIDS on women and children in sub-Saharan Africa: PEPFAR, the U.S. Strategy. Africa Today, 57(1), 64-76, 90-91. Rourke, M. (2006, November 26). Angelo D'Agostino, 80; priest founded home in Kenya for children with HIV. Los Angeles Times.
UNICEF. (2013, March 13). Statistics for Kenya. Retrieved from UNICEF: www.unicef.org/infobycountry/kenya_statistics.html#89
World Health Organization. (2008). HIV/AIDS epidemiological surveillance report for the WHO African Region: 2007 Update. Geneva, Switzerland: World Health Organization.
World Health Organization. (2010). Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach. Geneva, Switzerland: World Health Organization.
World Health Organization, UNAIDS, Unicef. (2011). GLOBAL HIV/AIDS RESPONSE: Epidemic update and health sector progress towards Universal Access. Geneva, Switzerland: World Health Organization. Centers for Disease Control and Prevention. (2012, December). HIV among Pregnant Women, Infants, and Children in the United States. Retrieved from CDC: www.cdc.gov
Centers for Disease Control and Prevention. (2013, March 13). Revised Surveillance Case Definitions for HIV Infection Among Adults, Adolescents, and Children Aged. Retrieved from CDC: www.cdc.gov
Cotton, M., Violari, A., Gibb, D., Owombe, K., Josipovic, D., Panchia, R., Babiker, A. (2012). Early ART followed by Interruption is Safe and Is Associated with Better Outcomes than Deferred ART in HIV+ Infants: Final Results from the 6-year Randomized CHER Trial. 19th Conference on Retroviruses and Opportunisitc Infections - Session 7 - Critical Treatment Issues in Women and Children. Seattle, WA: CROI. Retrieved March 13, 2013, from http://www.retroconference.org/2012b/Abstracts/45459.htm
Domek, G. J. (2006). Social consequences of antiretroviral therapy: Preparing for the unexpected futures of HIV-positive children. The Lancet, 367(9519), 1367-9.
Greenfield, R. A., & Steele, R. W. (2013, March 4). Pediatric HIV Infection. Retrieved from Medscape Reference: http://emedicine.medscape.com/article/965086-overview#a0104 Works Cited AIDS Progression -CDC Immunologic Categories for HIV-Infection in Children Based on Absolute CD4+ Counts CD4+ Count CD4+ Cell Count Months After Starting ART ART should be initiated in HIV-infected children aged ≥1 year with minimal or no symptoms
with the following CD4 values:
• 1 to <3 years: CD4 <1000 cells/mm3 or CD4 percentage <25% (AII)
• 3 to <5 years: CD4 <750 cells/mm3 or CD4 percentage <25% (AII)
• ≥5 years: CD4 ≤500 cells/mm3 (AI)* for CD4 cell count <350 cells/mm3BII*For CD4 cell count 350–500 cells/mm33)

ART should be considered for HIV-infected children aged ≥1 year with minimal or no symptoms with the following CD4 values:
• 1 to <3 years: CD4 ≥1000 cells/mm3or CD4 percentage ≥25% (BIII)
• 3 to <5 years: CD4 ≥750 cells/mm3 or CD4 percentage ≥25% (BIII)
• ≥5 years: CD4 cell >500 cells/mm3 (BIII)
-For considered RNA levels >100,000 copies increase recommendation for treatment
-treatment of all HIV-infected infants aged <12 months,
regardless of clinical status, CD4 percentage, or viral load (AI) for infants aged <12 weeks and (AII) for infants aged ≥12 weeks to 12 months). When to start ART? Questions?
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