Grandir

Pediatric classification and antiretroviral treatment (ART)

The WHO has revised its classification of HIV disease in children replacing the previous 3-staged definition with a new 4-staged definition bringing it more in line with reality as well as with adult classification. Stage 1 = asymptomatic. Stage 2 = moderately symptomatic. Stage 3 advanced symptomatic. Stage 4 = severely symptomatic / very advanced. Immunological classification based on CD4 level was also revised: the criteria of immunodepression are modified especially in younger children.

1. Confirmed diagnosis
(serology or virological test according to age)

2. Unconfirmed diagnosis (children under 18 months of age where virological tests are not available)
For infants under 18 months old, who present with clinical criteria presumptive of HIV infection at stages 3 and 4, ART should be initiated even in the absence of virological diagnosis. ART can be discontinued if the presence of HIV has been excluded by laboratory follow-up (virological tests as soon as possible or HIV antibody tests at 18 months if not breastfed).

Editor's note
(Dr Laurent Hiffler):

CD4 assays are becoming more readily available while access to virological tests is still quite limited. It is therefore useful to ascertain the CD4 levels of infants under 18 months of age when they are moderately symptomatic (WHO stage 2) and when their HIV infection could not be "virologically confirmed".CD4 count, in addition to helping with therapeutic prescription, is also a quasi-diagnostic when immunodepression is advanced or severe. In a region where HIV prevalence is high, the evidence of immunodepression shown by a fall in CD4 level is enough to infer HIV infection.




(*)Stabilize all IOs before initiating ART

(**)For children under 12 months: CD4-guided for LIP, oral hairy leukoplakia, thrombocytopenia, TB
(in case of TB : CD4+clinical assessment)



To learn more
WHO pediatric classification and recommendations www.who.int/hiv/pub/guidelines/
arv/en/index.html

Are children being left behind?
From North to South activism is on the rise

The "Treat the Children" campaign, started in June 2005 by the Global Aids Alliance (GAA), aims to improve access to PCR for early HIV testing in children before they are 18 months old, to develop low cost ARVs in child-appropriate doses and formulations and to reinforce the services of care and treatment, for example through defining a basic package of care outside of ARVS (cotrimoxazole, nutritional support, vitamin A). In GAA's recently published report the conclusion is dire: children are being "left behind" and rarely do donors or countries initiate or get involved in large-scale programs dealing with the care and treatment of HIV+ children.

ANECCA, an African network of health practitioners, has come up with practical suggestions to better integrate PMTCT and pediatric care and to overcome the main weakness of the system: timely diagnosis of children with HIV. Linking healthcare centers with labs that are equipped with PCR technology, routinely test all sick children in clinics and hospitals, post-partum testing of children born from mothers of unknown HIV status in order to provide them with post-exposure prophylaxis… it is an ambitious plan but one that is completely feasible in Africa.

To find out more
The campaigns "Treat the Children" and "Children Left Behind"
www.globalaidsalliance.org/
Children_Left_Behind.cfm
 
ANECCA's advocacy statement
http://www.sidaction.org/pro/
international/grandir/plaidoyer
 
ANECCA's website
www.rcqhc.org/

The best answer to last month's case study

Last month a case study was presented to the Growing Up Info readers. Here are some excerpts from the best answer we received.

The child is a minor and was left in the care of a relative who is not her parent. We are not told whether legal guardianship of the girl was obtained by the aunt, so I assume it was not, and the arrangement is informal within the family. Legally, we are not able to test the girl for HIV without her guardian's consent and the assent of the girl. I would acknowledge the aunt's fears and correct any misinterpretations of symptoms she associates with HIV. I would thank her for bringing the girl for evaluation and encourage her to continue doing so, and caring so well for her niece. I would examine the girl for clinical signs of HIV and stage her according to the revised WHO Clinical Staging system for HIV. The most crucial issue is to ask the aunt to discuss the issue with her brother and to seek my advice, if needed. I would supply my e-mail address for the father to ask confidential questions. I would explain the reasons why I feel uncomfortable to test the girl without the father's explicit permission and counselling and arrange a review date in some week's time to hear the outcome of family discussions. I would speak to the aunt about theoretical disclosure to the child, as a 12 year old would need much information and involvement in treatment decisions, if and when treatment was commenced. I would assure the girl that her health is in good hands and explain what she would need to do to keep healthy. I would enquire from the aunt whether she had identified a relative to explain sexual health matters to the girl, to make her less vulnerable. I would ensure that the maternal orphan had been registered with the social services.

And now for a crossword puzzle…

Congratulations to Dr Lynda Stranix from Zimbabwe for her brilliant answer.







Across
1.1 Stavudine
1.2 Parasitosis that becomes more frequent and more severe as immunodepression progresses
3. Nevirapine
5. Its use reduces significantly the onset of opportunistic infections
7. The process by which a living organism assimilates food and uses it for growth and for replacement of tissues
9. The active process the child and his/her family need to go through before and during ARV treatment
11. Vitamin that reduces episodes of diarrhoea

Down
A. Must be administered also in young HIV+ children
D. Its co-infection with HIV makes clinical management difficult
F. Abbreviation for opportunistic infection
H.1 Very frequent chronic lung condition in HIV+ children
H.2 It is small in HIV early encephalopathy
K. We should do it at every step of management
M. Lamivudine

Send your answers to: grandir@sidaction.org
A book to win!

Growing Up Growing Up… Charts!

Medical follow-up of children implies following their growth. A well filled-out growth chart represents a wealth of information, especially for vulnerable children (a failure to thrive shown on the weight/size charts, a small head circumference for age, or on the other hand, a regular weight, size and/or HC gain are all valuable information that complete clinical management). But often we don't have the tools!
 
The WHO is in the process of creating standardized tools now that they have concluded a multicentric study. They will be available at the end of April, 2006. But for now you can find all you need on the CDC website: weight/height charts and the head circumference from 0 to 3 years and weight/height from 2 to 20 for boys and girls and even more… So that you may assess the efficacy of your follow-up and/or spot a problem and so that parents and you too can see them Grow Up… go to your printers and Xerox machines!

To find out more
WHO growth charts
www.who.int/childgrowth/en/
 
CDC growth charts
www.cdc.gov/nchs/about/major/
nhanes/growthcharts/
clinical_charts.htm#Clin%201