Newsletter GRANDIR | La lettre d’information sur le VIH pédiatrique en Afrique

To simplify prescribing paediatric antiretrovirals for doctors, to make taking them easier for children and their families and to make them more rational from a public health perspective: these are the WHO’s goals over the last two years as they worked to define “ideal” strengths for paediatric ARVs which will go on the market in the next few years. These strengths are considered “ideal” in that they represent standardized prescriptions based on a new, simplified weight scale.

Some of these medicines in ideal strengths are already on the market: Cipla’s Triomune Baby (d4T 6mg / 3TC 30mg / NVP 50mg) is being used more and more. The new paediatric Kaletra/Aluvia dry tablet (Lopinavir 100mg / Ritonavir 25mg) is a significant advancement in facilitating the prescription of protease inhibitors for children. Finally, the UNITAID program is working with a laboratory to rapidly develop the following combination which is in line with the WHO recommended dosage: AZT 60mg / 3TC 30mg / NVP 50mg.

Many other ideal formulations still need to be developed: for example, AZT 60mg, 3TC 30mg, ABC 60mg, etc. Pharmaceutical manufacturers now have enough consensual data to swiftly develop production.

These ideal strength formulations are advantageous in that they can be prescribed according to the new WHO recommendations based on an extremely simplified weight scale consisting of only 7 weight categories: 3kg-4-kg / 4kg-6kg / 6kg-10kg / 10kg-14kg / 14kg-20kg / 20kg-25kg / 25kg-35kg.

Using the WHO’s recommendations as guidelines, GROWING UP has updated its own paediatric ARV dosage charts:

The WEB.foundation is a Dutch organization that develops tools to facilitate communication on HIV/AIDS with young people. The story of Bobo particularly caught our attention. This story, divided into two well-crafted 8-minute educational films (Be HIV free and Be aware, take care), playfully explains how HIV behaves in the human body, how to protect oneself against it… and also aims to promote adherence.

You can download the English versions from the WEB.foundation’s website and order the French versions on CD (at: info@lovecheck.org ).

The WEB.foundation has also created some interesting games but they are more limited in their use (as they were designed around specific scenarios depending on countries: South Africa, Zambia, etc.).

The 17th International Conference on HIV/AIDS, which was held in Mexico last August, paid serious attention to the needs of children living with HIV. Here are a few highlights:

- Children have often been ignored in the fight against AIDS but over the last few years the issue of children infected or affected by HIV has gained visibility. In the week leading up to the conference, there was an international symposium focusing entirely on children. During the conference, there was also a plenary session consecrated to children’s issues : a first.

- Many areas still need to be improved when it comes to paediatric prevention, care and treatment. For example, in 2007, less than 8% of newborns in developing countries were tested for HIV. Less than 4% of infants exposed to HIV received Cotrimoxazole in prophylaxis by the age of 2 months. While the overall number of children on ART increased (from 75,000 in 2005 to circa 200,000 in 2007), this represents only 10 % of the children living with HIV.

The Elizabeth Glaser Foundation presented interesting projects decentralizing PMTCT.

- In Uganda, PMTCT is integrated in district health centres (PMTCT services on 350 sites in 27 districts). Since 2000, this “district approach“ made it possible to distinctly increase the number of pregnant women tested as well as the number of mothers and newborns placed on antiretroviral prophylaxis.

- In Ivory Coast, a ”family approach” to PTMTC is preferred over an individual approach. It particularly aims at testing partners of pregnant women living with HIV and involving them more in the prevention of transmitting HIV to children.

The WHO reminded us of its most recent recommendations following the results of the CHER study (see Growing Up Info issue n° 17):

- HIV-infected children under 12 months of age should be placed on treatment as soon as the diagnosis has been established, regardless of the clinical stage of their illness or their immunological status. In the absence of early diagnosis by PCR, children under 12 months old who present symptoms of HIV infection should be placed on ART.

- In the case of exposure to nevirapine as PMTCT prophylaxis: the recommended first line ART is 2 INRT + 1 IP, to take in account resistances already selected by NVP as PMTCT prophylaxis . When PI is unavailable (the only protease inhibitor available since the retraction of Viracept being Kaletra in syrup form): 2 INRT + 1 INNRT (NVP).

This remains a sensitive topic for families as well as caregivers: children are not informed of their HIV status or they are told very late, even though they may have some doubts. This silence can lead to reluctance to take antiretroviral medicine. Once again this reiterates the importance of disclosure. And it is important for families and caregivers to make time for discussions with the children before, during and after disclosure.

Aminata, who tested HIV+ two months ago, comes in for a consultation because her 7-month old daughter Astou has been eating poorly for a few weeks and has had diarrhea for the last 8 days. Astou drinks powdered milk for babies over 6 months old that Aminata received free from an organization. She weighs 5 200 g at 64 cm. She weighed 5 600 g a month ago and 5 800 g two months ago. The clinical examination does not clearly indicate anything specific: the child is asthenic, urinates little, has a 37°9 C fever, and her abdomen is sensitive but soft. Astou is not on medication and she drinks herbal teas without any noticeable improvement.