Clinical Tracking and Management of HIV-Positive Children National Pediatric HIV Training 1

Introduction This is a practical exercise where you will track, document, and clinically manage an HIV-positive child over the course of several visits to the ART clinic In the exercise, you will gain experience using the HIV/ART card to correctly and thoroughly document clinical care of an HIV-positive child The practical exercise integrates what you have learned over the course of this training, and will help you apply it at your clinic

At every visit, a minimum package of care is required for an HIV-positive child Documentation of the visit HIV/ART Card, Pre-ART Register ART Register (if on ART) State duration on ART Growth monitoring – Wt, Ht,Edema, MUAC Assess Tb status Assess side effects of drugs Clinical assess for New OI’s and nutritional status Development assessment and functional status of child WHO clinical staging Provision and assessment of adherence to cotrimoxazole Recording of Medicines dispensed including RTUF ARV’s and adherence assessment Investigations- CD4 count, Hb, RPR, PCR,CXR,ZN Referral or linkage to other care programs Education and counseling on all relevant issues Family care 3

Accurate and thorough documentation is essential for effective care and tracking of HIV-positive children The HIV/ART Card is critical for provision of clinical care and tracking of HIV-positive children 4 Benefits of the HIV/ART Card:  Comprehensive record for the patients including detailed follow-up information  Prompts for the critical care indicators at each visit, guiding health worker on what to assess/provide  Enables longitudinal tracking of visits– easy to determine if a child is lost  Enables longitudinal tracking of care— able to see how a child is progressing over time (general health, growth monitoring, ARVs, etc)

5 HIV/ART Card (Front Side)

6 HIV/ART Card (Backside)

Agenda 7 Practical #1: James Okwii

Practical exercise #1: Complete the HIV/ART Card for James Okwii 8 You are working at the ART clinic at Pajule H/C IV in Pader district. James Okwii will make 4 visits to your ART clinic over the course of this practical, and you will be documenting each of them thoroughly on the HIV/ART card. James is an HIV exposed infant. He and his mother went through PMTCT and received NVP for prophylaxis. On Feb 2 nd 2010 when he was 6 week old a DNA PCR test was done and was started on cotrimoxazole prophylaxis. The Test results came back positive from the reference lab on March 15 th His mother receives James’ result from the EID care point on 26 th /03/2010 (age 14 weeks) and he is immediately referred and enrolled at the ART clinic. His pre- ART number is His mother is Margaret Abawaya. She resides in Adilang subcounty and Lokapel parish. LC1 zone is Katabok. Margaret is in care at Pajule H/C IV ART clinic (pre-ART number 436). Her telephone is Open an HIV/ART Card for James & fill in all relevant sections on front

On arrival at the clinic and you are on duty, what would you do for James? 9 Register and open a card for James Send to triage assess for Growth, development and nutrition status, Immunization status. Send to a counselor Send for clinician assessment.

Findings at 1 st visit James wt was 5.5 kg, Ht is 62 cm and has no edema. He is well and has not had any contact with adult with chronic cough. He is able to roll over, he smiles. What other information would you ask the mother? Immunization status? Missed last dose Is he still breastfeeding? Yes Fill in the information in James HIV care /ART card 10

1 st Visit How is James growth? What is his TB status? What is his functional status? What is his WHO stage? 11 Normal 1- no signs of TB W- Playing Stage 1

James’ 1 st visit (continued) Assess for ART eligibility Is James eligible for ART? Why or why not? Yes, all HIV-positive children under 24 months old must be initiated on ART immediately, regardless of CD4 or clinical staging 12

What actions would you like to take? He is eligible to start ART, so send for Adherence counseling Prescribe Cotrimoxazole Refer for immunization- DPTHepHib 2 Encourage to continue breastfeeding. Take samples for CD4 count and Hb. 13 What dose of cotrimoxazole would you prescribe? Indicate the amount to dispense for 1 month. CD4 results – 30% and Hb is 14g/dl Fill in the card. When would be your next appointment and for what purpose? Next appointment – 2 nd April 2010 for adherence counseling. 240 mg od; 60 tablets

2 nd visit James was brought back for counseling on 2 nd April The counselor reported she needed another counseling session. However the mother reported he had a pus discharge from the left ear. On examination this was the only significant finding. She had come back with 46 pills of cotrimoxazole. Wt is 5.5kg Calculate the adherence level and fill in James card and give the next appointment date. 14

2 nd visit 15 Adherence to cotrimoxazole How is James growth? What is his TB status? What is his functional status? What is his WHO stage? (14/14) x 100 = 100%- good 1- no signs of TB W- playing Stage 2 Normal What drugs and advice do you prescribe for James? Amoxyl syrup, ear wicking, What is the next appointment date and for what reason? 9 th April 2010 for adherence counseling and review of ear infection.

3 rd Visit James is brought on April 9 th 2010.The counselor says James mother is ready to start ARV’s. During your review you find that James still has the ear infection but the pus discharge has reduce. However he has developed oral candidiasis. His wt is 5.3 kg and has no oedema. Fill in the card 16

You are going to initiate James on ART What key steps are included in the initiation process for James? 17 1.Adherence counseling Counseled and mother is ready to provide ART to James You refer to lab for Hb test. Result is 14 g/dL. 2. Hb Test 4. Determine ART regimen (note that your clinic does not have LPV/r) 5. Prescribe and give the right formulation and dose of ARVs  NVP should be avoided if possible because James was exposed to NVP during PMTCT  No EFV because he is < 3 years of age The appropriate 1 st line regimen is: AZT + 3TC + NVP (must use NVP because no LPV/r) 3. Determine any contra-indications Give Triple FDC of AZT/3TC/NVP (60/30/50 mg) in morning and Duo FDC AZT/3TC(60/30 mg) in evening. Because weight is between 3 and 5.9 kg, the daily dose is 1 tablets. Total amount for 2 weeks Triple FDC- 14 and DUO FDC 14 pills.

What is next appointment date and why? 23 rd April for review, adherence counseling and refill of ARV’s and Septrin 18

4 th Visit James is brought back on April 26 th The mother reports he had developed a mild measles like rash on the neck which spread to the trunk. However there was no fever and no mucous membrane involvement. She report that this started after 10 days on ARV’s. His weight is 5.5 kg. she returns with no cotrimoxazole pills however she still had some 4 pills of AZT/3TC/NVP and 4 pills of AZT/3TC. She mentioned that she was afraid to continue treatment and had no money to return to the health facility What key issue do you note with James. 19

Key issues Missed appointment Side effects of ARV’s most probably NVP Poor adherence. Calculate the adherence levels and fill in the card 20

Adherence 21 Margaret returns with the following:  4 tablets of AZT/3TC/NVP  4 tablets of AZT/3TC  0 tablets of Cotrimoxazole  Calculate the adherence percentage for each pill, and assess as Good, Fair or Poor using instructions on the ART card. (10 / 16) x 100 = 62.5% Poor (60 / 64) x 100 = 94% Fair

What actions do you take? Adherence counseling Counseling about side effect- – Hydrocortisone cream Continue to take ARV’s Refill the ARV’s and Septrin What instructions do you give the mother? 22

What dose and amount of ARV’s and Cotrimoxazole do you give James ARVs AZT/3TC/NVP(60/30/50mg) 1 BD for 1 month Total amount 60 pills for 30 days. Cotrimoxazole(120mg) 240 mg od 60 pills for 30 days Instructions: bring back the child if the rash becomes worse. 23

Summary: High-quality care and tracking of HIV- positive children depends on good documentation Good Documentation High Quality Clinical Care of HIV+ Children Leads to… Requires…

QUESTIONS?