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WHO Department of Maternal, Newborn, Child and Adolescent Health Department of HIV/AIDS.

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Presentation on theme: "WHO Department of Maternal, Newborn, Child and Adolescent Health Department of HIV/AIDS."— Presentation transcript:

1 WHO Department of Maternal, Newborn, Child and Adolescent Health Department of HIV/AIDS

2  Common  High morbidity & mortality  Could be an indicator disease

3 …to provide a summary of key evidence and practice recommendations on treatment of the main skin and oral conditions in HIV-infected adults and children

4 Criteria for selection  Burden of disease  Severity  Impact on prognosis of HIV  Marker of low CD4  initiation of ART  Applicability for primary health care levels in resource-poor settings

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6 Health proffesionals Policy makers Managers of HIV/AIDS control programmes in settings with HIV infection, primarily where resources are limited.

7  No standardized criteria presently  Extent of tumour alone may be insufficient  Categorization of KS into mild/moderate & severe symptomatic based on the original ACTG tumour extent criteria

8 * Pending approval by the WHO guideline Review Committee

9 Recommended Regimens*Rationale Vincristine with Bleomycin and Doxorubicin (ABV) Bleomycin with Vincristine (BV) (When available or feasible) Liposomal anthracyclines (doxorubicin or daunorubicin) Though Liposomal anthracycline treatment is the standard of care, they are: Expensive not widely available remain under patent require cold storage Kaposi Sarcoma * Pending approval by the WHO guideline Review Committee

10 DiseasePending Recommendation * Rationale Mild SD Topical ketoconazol 2% 2-3 times / week for four weeks maintenance treatment once / week as needed Evidence for treatment of SD in HIV very limited Evidence is strongest for Ketoconazole General concensus that combination of antifungals and corticosteroids is effective Potential side effects with topical corticosteroids Quality of evidence for ART alone is limited & of very low quality Severe SD Topical antifungals (e.g. ketoconazole 2%) and topical corticosteroids * Pending approval by the WHO guideline Review Committee

11 Pending Recommendation * Rationale ART should be considered as the primary treatment Evidence for treatment of PPE in HIV very limited Some evidence is available for resolution of PPE with ART General concensus: ART initiation, with or without symptomatic therapy, as the best option Additional symptomatic therapy Antihistamines Topical corticosteroids * Pending approval by the WHO guideline Review Committee

12 Pending Recommendation * Rationale ART should be considered as the primary treatment Evidence base for all of the interventions was of very low quality Expert opinion and general concensus: ART as the primary treatment Should not discontinue the ART Additional symptomatic therapy oral antihistamine if no adequate response, add: topical corticosteroids / oral itraconazole / permethrin 5% cream * Pending approval by the WHO guideline Review Committee

13 Disease typePending Recommendation * Rationale Tinea Not extensive Topical terbinafine 1% Topical miconazole 2% No evidence to determine if one class of antifungal is superior Terbinafine, Miconazole In“WHO essential medicine list” widely available Terbinafine offers shorter duration of therapy For extensive tinea: Expert panel favoured griseofulvin rather than terbinafine because of the latter’s higher cost Tinea Extensive, hair/nail involvement Oral griseofulvin If there is no response: Oral terbinafine or itraconazole * Pending approval by the WHO guideline Review Committee

14 Pending Recommend ation* Rationale Acyclovir (at any time in the course of the disease) Acyclovir, famciclovir and valaciclovir are all effective The safety profiles of all three drugs similar Acyclovir Better availability Costs less * Pending approval by the WHO guideline Review Committee

15 DiseasePending Recommendati on* Rationale Classical scabies 1 st line: Permethrin 5% 2 nd line: Oral ivermectin Permethrin appears to be the most effective treatment for scabies The limited data on crusted scabies in HIV-infected patients suggest a good effect of oral ivermectin Crusted scabies 1 st line: Oral ivermectin * 2nd line: Permethrin 5% *avoid in children <15kg * Pending approval by the WHO guideline Review Committee

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17 Pending Recommendation * Rationale Oral fluconazole When fluconazole is not available or contraindicated: nystatin suspension or pastilles, or clotrimazole troches ketoconazole, fluconazole, itraconazole and clotrimazole are all effective Oral fluconazole Highly effective Single dose Better bioavailability Less toxicity Less drug interaction * Pending approval by the WHO guideline Review Committee

18 Pending Recommendation * Rationale Suspected causative drug should be promptly discontinued and supportive therapies should be offered Absence of good evidence to support the use of oral steroids, immunoglobulins or cyclosporine-A Steroids may: Decrease survival in the paediatric group Place the HIV-infected patient at risk for OI / sepsis * Pending approval by the WHO guideline Review Committee

19 After input from dermatologists in the field, the tool was refined to include better diagnostic criteria, additional diagnoses of relevance, additional pictures of children and of skin diseases in diverse subjects.

20 Common to all conditions…  Research in HIV infected  Research in Children  Standardized outcome measures  Well designed prospective, randomized double blind studies with adequate power  Effect of ART … does it manifest as an IRIS

21 Contributors to the GRADE systematic reviews and supporting evidence Esther Freeman (Harvard Medical School, USA), Toby Maurer (University of California, USA), Oluwatoyin Gbabe (Stellenbosch University, South Africa), Charles L. Okwundu (Stellenbosch University, South Africa), Miriam Laker (University of California, USA), Philippa J. Easterbrook (World Health Organization, Switzerland), Jeffrey Martin (University of California, USA), Martin Dedicoat (Birmingham Heartlands Hospital, United Kingdom).Andrew Anglemyer (University of California, USA), Anurag K. Agarwal (Baylor College of Medicine, USA), George W. Rutherford (University of California, USA). John Stephen (St. John's Medical College, India) Tony Raj (St. John's Medical College, India), Kedar Radhakrishna (St. John's Medical College, India), Tinku Thomas (St. John's Medical College, India). Ser Ling Chua (University Hospital Birmingham, United Kingdom), Kedar Radhakrishna (St. John's Medical College, India), John Stephen (St. John's Medical College, India), Mike Zangenberg (World Health Organization, Switzerland).Mamaduo O. Diallo (Centers for Disease Control and Prevention, USA), Magdy El-Gohary (University of Southampton, United Kingdom), Esther J. van Zuuren (Leiden University, Netherlands), Hana Burges (University of Southampton, United Kingdom), Liz Doney (University of Nottingham, United Kingdom), Zbys Fedorowicz (Cochrane Collaboration Awali, Bahrain), Michael Moore (University of Southampton, United Kingdom), Paul Litle (University of Southampton, United Kingdom).Dunja Vekic (St. Vincent’s Hospital, Australia), Lisa Abbot (St. Vincent’s Hospital, Australia), Emily Asher (University of California, USA), Margot Whitfeld (Skin and Cancer Foundation, Australia). Elissa M. McDonald (University of Auckland, New Zealand), Johannes de Kock (Wanganui Hospital, New Zealand), Feliz S.F. Ram (Massey University, New Zealand), Cristina C. Chang (Monash University, Australia), Vivek Naranbhai (Doris Duke Medical Research Institute, South Africa), Allen C. Cheng (Monash University, Australia), Monica Slavin (Peter MacCallum Institute, Australia), Abijeet Waghmare (St. John's Medical College, India).Paul Harris (London School of Hygiene & Tropical Medicine, United Kingdom)Elizabeth D. Pienaar (Medical Research Council, South Africa), Taryn Young (Medical Research Council, South Africa), Haly Holmes (University of Western Cape, South Africa). WHO Staff and Consultants Lulu Muhe, Philippa Easterbrook, Mike Zangenberg, Elizabeth, Frank Lule, Kasonde Mwinga, Meg Doherty, Rajiv Bahl, Wilson Were, Peggy Henderson,


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