1. Pediatric HIV/AIDS Overview
Courtesy of:
International Center for AIDS Care and Treatment Programs
Columbia University
Mailman School of Public Health
Unit should take approximately 9 hours, 30 minutes to implement.
Step 1: Overview of Pediatric HIV (Slides 2 – 20) – 30 minutes
Step 2: Care of the HIV-Exposed Infant (Slides 21 – 60) – 100 minutes
Step 3: Infant Diagnosis (Slides 61 – 104) – 90 minutes
Step 4: Pediatric Disclosure (Slides 105 – 135) – 60 minutes
Step 5: Care of HIV-Infected Infants and Children (Slides 136 – 139) – 10 minutes
Step 6: Clinical Manifestations of HIV/AIDS (Slides 140 – 156) – 40 minutes
Step 7: Routine Care for the HIV-Infected Child (Slides 157 – 192) – 60 minutes
Step 8: Pediatric ARV Therapy (Slides 193 – 246) – 120 minutes
Step 9: Pediatric Adherence (Slides 247 – 275) – 60 minutes

2. Learning Objectives: Overview and Challenges
Describe the scope of the pediatric HIV/AIDS epidemic in Sub-Saharan Africa and Ethiopia
List the unique challenges in the care and treatment of children with HIV/AIDS and discuss ways to overcome these challenges
Start to consider the programmatic requirements for implementation of effective HIV care in children
By the end of the presentation the participants will be able to

3. Historical Perspective of Pediatric HIV: Sub-Saharan Africa
the first cases of pediatric HIV were first observed in Rwanda, the Democratic Republic of Congo, and Uganda
Mid 1980’s longitudinal cohort studies started in East Africa (Kigali, Kampala, Kinshasa, Nairobi) to study maternal to child transmission and the natural history of HIV-exposed and infected children
In 1988 the first specialist clinic started in Uganda 3

4. Historical perspective of pediatric HIV: Ethiopia
The first HIV exposed newborn was identified in 1986
Prior to 2002 pediatric HIV care is limited to provision of cotrimoxazole preventive therapy &other supportive care
Fee ARVs were made available between In few private institutions and government hospitals selected pediatric AIDS cases were treated with crushed adult tablets.
In 2005 pediatric ARV formulations were available on free basis and since then pediatric ART service has expanded to many health institutions 4

5. Estimated Number of Children Living with HIV/AIDS in 2005
Western &
Central Europe
4000
[<8000]
Eastern Europe & Central Asia
6900
[3400 – ]
North America
11 000
[3500 – ]
East Asia
6400
[2000 – ]
North Africa & Middle East
31 000
[ – ]
Caribbean
22 000
[9800 – ]
South & South-East Asia
[ – ]
Sub-Saharan Africa
2.0 million
[1.5 – 3.0 million]
Latin America
32 000
[ – ]
Oceania
3000
[830 – 7900]
Of the 2.3 million children living with HIV, 2 million are in Sub-Saharan Africa
UNAIDS (2006)
Total- 2.3 million
Sub-Saharan Africa-2 million

6. Estimated Number of Children < 15 years Newly Infected with HIV in 2005
Western &
Central Europe
200
[<400]
Eastern Europe & Central Asia
2300
[1400 – 3900]
North America
500
[<1000]
East Asia
2300
[1000 – 4100]
North Africa & Middle East
6900
[3200 – ]
Caribbean
3700
[2100 – 5800]
South & South-East Asia
44 000
[ – ]
Sub-Saharan Africa
[ – ]
Latin America
5000
[3500 – 8000]
Oceania
1100
[400 – 2800]
There were about 540 newly infected children in 2005, majority of the new cases 470,000 were sub-Saharan Africa.
In Ethiopia it is estimated that 25,000 new pediatric cases occur annually
UNAIDS (2006)
Total-540,000
Sub-Saharan Africa-470,000

7. Estimated Number of Pediatric Deaths Attributed to HIV/AIDS in 2005
Western &
Central Europe
<100
[<200]
Eastern Europe & Central Asia
1200
[620 – 2300]
North America
<100
[<200]
East Asia
1400
[530 – 2700]
North Africa & Middle East
4900
[2000 – 9500]
Caribbean
3100
[1600 – 5100]
South & South-East Asia
29 000
[ – ]
Sub-Saharan Africa
[ – ]
Latin America
2900
[1800 – 4900]
Oceania
600
[200 – 1800]
Death in children < 15 years of age due to HIV is disproportionately higher in sub-Saharan Africa. One of the contributing factors is lack of early infant diagnosis. Half of all HIV-infected children will die before their second birthday if they are not provided with care and treatment
UNAIDS (2006)
Total- 380,000
Sub-Saharan Africa-330,000

8. MTCT accounts for 90% of new HIV infections in Children
Coverage of antiretroviral therapy
Access to mother-to-child prevention services (all pregnant women)
Coverage of HIV-infected mothers who received antiretroviral prophylaxis
7.0
20.0 5 10 15 20 25
2003
2005 %
7.6
9.0
3.3
9.2
UNAIDS (2006)
PMTCT coverage in low and middle income countries
These three graphs show the Comparison of 2003 and 2005 data on the coverage
of antiretroviral therapy, access to mother-to-child prevention services
and coverage of HIV-infected mothers who received antiretroviral prophylaxis to prevent mother-to-child transmission
Take home message
Only 20 percent of HIV –infected pregnant women in low and middle income countries received HAART in 2005
Only 9 % of women had access to PMTCT services
Only 9.2% of HIV infected women received antiretroviral prophylaxis for PMTCT

9. What is happening to HIV-infected children in Ethiopia?

10. HIV Population Size by Sex and Age – Ethiopia 2005
At an early age < 14 years of age the gender distribution is the same. However after adolescence and during early adulthood, females out number males. There are several reasons for this.
During infancy and early childhood most children acquire HIV infection via MTCT
During adolescence children are becoming increasing sexually active and acquire HIV like adults- from sex and IV drug use
Solicit explanations from the audience.
The other point to note is that disease progression is very rapid in children so as you can see from the graph the number of infected children begins to fall after 4 years of age- this is because we know that without treatment 75% of children will be dead before they reach age 5

11. Summary of Pediatric HIV/AIDS in Ethiopia, 6th Report- 2006
135,000 children are estimated to live with HIV
43,000 are in immediate need of ART
106, 000 HIV positive pregnancies annually
30,000 HIV positive births annually
21,000 deaths due to HIV in children annually

12. Pediatric HIV care and treatment in Ethiopia
Over 66,000 people are receiving ART in Ethiopia, 2007
However, only 4.7% (3144) are children
Only 7.2% (3144) of the 43,000 eligible children were on ART as of May 2007 based the 2006 estimate
Although there has been a dramatic increase in number of children who are on ART since there are still several thousand children in need of care and treatment in Ethiopia
It is estimated that 43,000 children in Ethiopia are in need of ART
As of May eligible children are receiving ART
Of the estimated 69,973 people receiving ART in Ethiopia only 4.7 % are children.
FMOH 2007

13. Why are so few children in need getting care and treatment?
Technical barriers
Diagnostic challenges
Relative failure to implement effective PMTCT
Infrastructure & system capacity limitations
Human resource requirements
Developmental challenges in pediatrics
Children are not small adults
HIV and children
Complexity of ART administration
There are several barriers which have contributed to the slow uptake of services for infected children

14. BARRIERS TO CARE: Technical
Diagnostic challenges
Identification of exposed infants, virologic testing of infants <18 months, stigma, consent, etc)
Relative failure of effective PMTCT
Low PMTCT up take and follow up
Infrastructure & human resource requirements
Challenge of transforming health systems accustomed to acute, episodic care into systems capable of providing chronic care
Human resource requirements
Human resource training
High staff turnover
Lack of pediatric comfort amongst providers
Diagnostic challenges
Identification- There is no systematic means of identifying HIV-exposed infants early so they can be engaged in care
Need for virologic testing of infants < 18 mo
Barriers to HIV testing of children (stigma, consent, etc)
Failure of PMTCT
Low ANC coverage
Missed opportunities( NO point of service testing, lack of testing in L&D etc…Lack of systematic follow-up for mothers and infants
Infrastructure and Human resource
Lack of systems for chronic care (appointments, medical records, community outreach)
Human resource
Staff turn over
Limited training
Lack of pediatric training and provider comfort with pediatric patients

15. BARRIERS TO CARE: Developmental Challenges
Children are not small adults
Different mode of transmission > 90% from MTCT
Growth and development
Immature immune system
Dependent on care giver
HIV and children
Immature immune system + high viral load → rapid disease progression
High morbidity and mortality
Half will be dead by 2 years and ¾ will be dead by 5 years of age if they are not provided with HAART
Complexity of ART administration
Lack of palatable pediatric formulations
Weight-based dosing
Dependence on family for medication supervision
We are faced with specific challenges when caring for children with HIV
There are unique differences between caring for children and adults.
HIV has a greater toll on the immature immune system making disease progression very rapid in children.
Rapid progressors (25-30%)
Acquires infection in utero / early perinatal period
Death by age 1year
2) Early symptomatic (50-60%)
Death by age 3-5 years
3) Long-term survivors (5-25%)
Live beyond age 8
Limited number of pediatric formulations
Need for Weight-based dosing
Pediatric adherence depends on child and caregiver

16. Children with HIV Do Well on Treatment
• Dramatic improvements in morbidity and mortality have been seen in high-resource settings secondary to:
– Early infant diagnosis
Accessible pediatric health services
Widespread use of OI prophylaxis (cotrimoxazole)
Widespread use of HAART
Successful perinatal prevention

17. Children in Low resource settings also Do Well on HAART
CD4+ Percent
78 children in Cote de Ivoire were treated with ART over a period of 21 months. Only 4 of these children were < 2 years. Mean age of the cohort was 7.2years.The graph shows the mean for CD4% before and after initiation of treatment. There was an increase in the mean CD4% from 7.7% to 24%
Modified from Fassinou et al., AIDS, 2004
HARRT
Initiation
Time on HAART (months)

18. How do we overcome these barriers?
Expand and strengthen entry point for pediatric service
Establish strong linkage between PMTCT & ART service
Family centered approach
Under 5 clinics – opt out approach
Effective linkage with orphanage & community
Service decentralization and roll out
Expand early infant diagnosis (use of DBS /PCR)
Enhance case finding and referral
Link PMTCT to infant follow-up
Ensure follow-up and comprehensive care for exposed infants

19. How do we overcome these barriers?
Effective PMTCT
Engage mothers and their families in comprehensive care and treatment
Point of service testing for pregnant women in the ANC, MCH, labor and delivery and postnatal clinics
Provide HAART for eligible mothers and effective prophylaxis for mothers who are not eligible
Pediatric Care and Treatment
Provide minimum standard of care for all HIV-infected children
Provision of HAART for all eligible children
Family support and psychosocial support
Increase availability of and access to pediatric ART

20. Conclusion
Pediatric HIV care and treatment can be implemented in resource limited setting
Children have unique needs and can be challenging but not impossible
Early diagnosis and prompt treatment will improve survival
PMTCT is the way to safeguard children's health and prevent further infections in children
Move from theory to practice. We will discuss all these challenges during the next 2 weeks and place particular emphasis on implementation of programs in your setting