Care and Treatment of Children and Adolescents with HIV - The Barbados Experience.

Transcription

1 Care and Treatment of Children and Adolescents with HIV - The Barbados Experience. M. Anne St John Consultant, Department of Paediatrics Queen Elizabeth Hospital, Barbados Hon Professor, Child Health, Faculty of Medical Sciences UWI, Cave Hill Campus 8th CCAS HIV/AIDS Workshop CHART-CCAS-CDC 3rd Joint Meeting Rose Hall Resort &Spa Montego Bay Jamaica, Aug , 2011

2 Background Caribbean- small share of global HIV epidemic Second to Sub-Saharan Africa prevalence of HIV infected persons (UNAIDS) -0.9 to 1.2% Paediatric HIV cases- 6% total HIV cases Research in developing countries.. HAART intervention - reduction of mortality (x 5) - 90% survival to adulthood (UNAIDS)

3 Barbados population 270,000, land area 166 sq. miles Extremely small and dwarfed by many C bbean territories Minimum overall HIV prevalence % PMTCT coverage % Prevalence testing in pregnancy - 93% VCT (Ministry of Health report 2008)

4 Historical perspective: 1985: first case of Paediatric HIV diagnosed No ART available for HIV infected patients 1995: PMTCT free of charge to all HIV infected pregnant women- policy Ministry of Health 1990 increasing VCT from 20% to 93% in Preval. preg. women %.. 10 yr

5 Observations Changes in trends in the Paediatric HIV epidemic care and treatment since inception of the epidemic surveillance from 1984 in Barbados

6 Care and Treatment of Children and Adolescents with HIV - The Barbados Experience.

7 Queen Elizabeth Hospital- Barbados 600 bed- only tertiary health care institution

8 Subjects and Methods Review period decade : Jan.1st Dec.31st 09 Study population : Confirmed infected patients (31) diagnosis age to 16th birthday

9 Follow-up ambulatory setting Specific QEH Paediatric Outpatients Clinic.by PID consultant in a general clinic serving other children. Specific Public Health nurse- midwife from LRU dedicated clinic for adults attendance for counsellng of mother/ guardian in Private (ID) Paediatrician s office

10 Procedure History and follow-up at clinic Clinical examination; growth, dev. ht, wt Visits, hospitalisations Blood investigations- CD4, VL,CBC, U&E, LFT, other

11 Diagnosis Case definition- Paediatric HIV infection < 18 months pos. 2 PCR tests (DNA/RNA) > 18 months pos. HIV commercial enzymelinked immuno-adsorbent assay (ELISA)

12 Staging Clinical Stages - CDC definitions - Stage N, A, B, C Immunological staging CD4 - No suppression, mild, moderate, severe suppression (% 1-5 yr ; absolute lymphocyte count > 5 yr)

13 Rapid progressors Slow progressors

14 Management follow-up (3-4 monthly) or care sooner as necessary End of clinic..weekly basis - defaulting care providers are contacted/tracked by PH nurse rescheduled appt. as per standard clinical care and lab monitoring protocol - National Guidelines (Ministry of Health)

15 Treatment WHO guidelines Treatment HAART 2 NRTIs - Zidovudine, Lamivudine 1 NNRTI - Nevirapine (older children- Efavirenz tab)

16 Treatment Antiretroviral medication First line - 2 NRTs plus 1 NNRTI Second line PI (lopinavir/ ritonavir) replaced NRTI 3 NNRTI s selection made depending on resistance pattern

17 Non-specific treatment Trimethoprim/ sulfa prophylaxis - < 5 years of age, > 5yr CD4 < 350, h/o PCP Nutritional support Specific immunisation guidelines Education Other needs as indicated

18 Sources of data: Paed Dept. surveillance database medical records Data recording: Excel microsoft program

19 Data extracted for analysis Age Year of diagnosis Sex Family demographics Sequential viral loads, CD4 counts Treatment- HAART Outcome: staging, co-infection, CD4, VL Morbidity, mortality

20 Results

21 Distribution of patients by age (n=31) (%) male female Sex 1 set of twins- female

22 Family Demographics All single parents Siblings - 12 in 9 families..same mother different partners - 9 uninfected - 3 deaths (HIV infected) - 3 families

23 Family Demographics AIDS orphan status 1 father dec d (HIV) prior to 2000 (3%) 7 mothers dec d (HIV) prior to 2000 (23%) 6 mother dec d during study period (19%)

24 Sociological Status Care provider No. % Parent father 1 3 mother Other relative 5 16 State home * 1 3 State institution 1 3 * After mother s death

25 Clinical staging (CDC) (n=31) (%) N A B C Clinical stage 3

26 No. (%) Rapid progressors* 9 29 (symp/ signs/ immunity at < 4 yrs) Slow progressors (symp/ signs/ immunity at > 4 yrs) * Clinical, immunity improved with HAART

27 Clinical manifestations HIV related Manifestation No. (%) Lymphadenopathy 1 3 Candidiasis 4 13 Skin manifestations 2 6 Pneumonia 4 13 Parotitis 1 3 Encephalopathy 1 3

28 No cases of tuberculosis No cases of cancer

29 Clinical manifestations non-specific Manifestation No. (%) Asthma 6 19 Epilepsy 1 3 Cognitive deficits/ LD/ ADD 3 10 Behaviour issues- adol. 1 3 Precocious puberty 1 3

30 Follow-up Location No. (%) QEH Paed. specialty Clinic Privately - Paediatrician ID 1 3

31 Growth outcome 6 (19%) of the children growth below the 3rd percentile weight for age and height for age, little improvement over the period of study The remainder adequate growth velocities for age

32 Clinical course NO. (%) Hospitalisation hospitalisations in total 11 (65%) HIV related illnesses

33 Treatment with HAART (n=12) Prescribed Adherence No. (5%) No. (%) Female Male cases of NRT resistance (mother s test) Adherence improved during study period

34 Additional laboratory data LFT s acutely abnormal - 1 patient Hospitalised, demised acute hepatic failure Dx NVP hepatopathy

35 Support services Service No. (%) Psychology referral 1 3 Psychiatry referral 1 3 Dermatology referral 1 3 Gynaeclogy 2 6

36 Other challenges Poor adherence of parent/ guardian Consequences after parent/s death Dysfunctional family unit with death of parent and variable care providers Stigma and discrimination family

37 Outcome Pregnancy 2 (6%) Mothers defaulted 3 (10%) Poorly compliant 2 (6%) Deaths 4 (13%)

38 Patient mortality - 13% of infected patients Year No. (%) Ages -1 1/2 yr, 6 yr, 7 yr, 14 yr

39 Causes of death Number Cause identified 1 Nevirapine reactionfulminant hepatic failure 1 Septicaemia 2 cause undetermined (home)

40 Challenges with medication treatment No treatment available -stockouts supplier/ documentation funding associated delays Drug formulations (liquid form) unavailable from supplier periodically

41 4 patients transferred 2 male 2 female to Ladymeade (adult) Clinic for HIV care age > 16

42 HIV Infection among Children in Barbados. 47 children : 5 ( ), 14 ( 86-90), 21( 91-95) 91% MTCT ; 87% symptomatic Median age of death in 50% was 12 months 73% mortality < 1 year olds, mostly (PCP) (PRE- ART availability, prophylactic TMP/SMX given) West Indian Med J 2000; 49(1) 43 Kumar, St John

43 Conclusions Pattern of significant change. improved quality of care and treatment.. Decline in new cases Decreased morbidity Decreased mortality

44 Acknowledgements Ira Waterman Parents Staff - nurses and and residents of Paed Unit

45 Thank you..from Barbados