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Module 1:
HIV Information
Broad objective
 At the completion of this module, participants shall
acquire information and knowledge on HIV infection,
transmission, progression, management and prevention
according to the national HTC curriculum.
Specific Objectives
 Define HIV, HIV infection and AIDS
 Describe the epidemiology of HIV in Adults and Children
 Describe basics of human immune system;
 Describe the modes of HIV transmission;
 Describe biology and natural progression of HIV in adults
and children;
 Describe common HIV related conditions
 Describe HIV prevention strategy including stigma reduction
Definitions
What is HIV?
 HIV stands for Human Immunodeficiency Virus. It is a
retrovirus.
 HIV Infection is the state where the virus is in the
body. In most instances this is the asymptomatic state,
which is a prelude to AIDS.
 AIDS stands for Acquired Immune Deficiency
Syndrome. “Acquired” means it is transmissible, and
“Immune-Deficiency” means it damages the body
defense system “Syndrome” refers to a group of
illnesses.
Unit 1:
Overview and Epidemiology
Historical background of HIV
1981 – Doctors in the United States recognized
Kaposi’s sarcoma (KS) in homosexual males, a
condition previously unreported in healthy adults. Later
they recognized that all these patients were immuno
suppressed.
 1983/4 – Scientists described the cause of this
acquired immunodeficiency syndrome (AIDS)
as a retrovirus:
1. Lymphadenopathy Associated Virus (LAV).
2. AIDs Associated Retrovirus (ARV).
3. Human T-lymphotrophic Virus ? (HTLV-?).
Historical background of HIV
cont’d
 1984– The first case in Kenya was described
 1986 – Human Immunodeficiency Virus (HIV) was
accepted as the international designation for the
retrovirus in a WHO consultative meeting
 1996 – ARVs became available in the world.
 1997 – ARVs became available in the private sector in
Kenya.
 2003 – ARVs became available in public sector in
Kenya.
 2006 – Approximately 90,000 Kenyans are taking ARV
treatment.
GLOBAL AIDS INDICATORS
(UNAIDS 2008)
 Globally, there were an estimated 33 million [30 million–36
million] people living with HIV in 2007
 The annual number of new HIV infections declined from 3.0 million
[2.6 million– 3.5 million] in 2001 to 2.7 million [2.2 million–3.2
million] in 2007.
 Overall, 2.0 million [1.8 million–2.3 million] people died due to
AIDS in 2007, compared with an estimated 1.7 million [1.5
million– 2.3 million] in 2001.
 Southern Africa continues to bear a disproportionate share of the
global burden of HIV: 35% of HIV infections and 38% of AIDS
deaths in 2007 occurred in that sub region. Altogether, subSaharan Africa is home to 67% of all people living with HIV.
Estimated Number of Women, Young,
Children Newly Infected With HIV During
2007
 Women account for half of all people living with HIV worldwide,
and nearly 60% of HIV infections in sub-Saharan Africa. Over the
last 10 years, the proportion of women among people living with
HIV has remained stable globally, but has increased in many
regions.
 Young people aged 15–24 account for an estimated 45% of new
HIV infections worldwide.
 An estimated 370 000 [330 000–410 000] children younger than
15 years became infected with HIV in 2007. Globally, the number
of children younger than 15 years living with HIV increased from
1.6 million [1.4 million–2.1 million] in 2001 to 2.0 million [1.9
million–2.3 million] in 2007. Almost 90% live in sub-Saharan
Africa .
HIV among children
 It is estimated that more than 90% of children living
with HIV acquired the virus during pregnancy, birth or
breastfeeding—forms of HIV transmission that can be
prevented. A small fraction of HIV infections in children
are caused by contaminated injections, the transfusion
of infected blood or blood products, sexual abuse,
sexual intercourse (although this is a significant mode
of transmission among adolescents), or scarification
 In 2007, an estimated 270 000 [250 000–290 000]
HIV-infected children younger than 15 years died
because of AIDS—more than 90% of them in subSaharan Africa
Epidemic update: Kenya
Indicator
National adult
prevalence: 15 - 49
years
Total Number of HIV
infected people
NASCOP 2005
6.7%
Women-8.7%
Men 4.6%
1.25Million
KAIS 2007
7.4 %
Women 9.2%
Men 5.8%
1.4 Million
(between 15 –
64 years)
Number of children
infected
Number on ART
increasing
End August 2006
120,000
Adults-88589
Children-6744
140, 000 (15 –
64 years)
Number needing ARV
250,000
390,000 (15 –
64 years)
Epidemiology of HIV/AIDS in Children
(under 15 yrs)
Global
Sub-Saharan
Africa
Kenyan
estimates
No. living with HIV 2.5 million
2.25 million
100 –
150,000
No. Newly infected 700,000
616,000
34,000
No. AIDS deaths
450,000
18,000
500,000
Epidemiology/Impact of HIV/AIDS
in Kenya
60% medical beds- HIV/AIDS
40% Paediatric beds-HIV/AIDS
>50% TB patients – HIV +
>25% STI patients – HIV
Health workers face both the medical and social
challenges of HIV/AIDS on a daily basis
HIV transmission modes
HIV is mainly transmitted: through unprotected sexual intercourse with an infected
person
 through exposure to blood, blood products, body fluids and
other tissues, e.g. organ transplants
 and during pregnancy, birth, or breastfeeding from infected
mother to child
The fluids from an infected person that can potentially transmit
HIV include:
 Blood
 Semen
 Vaginal fluid
 Breast- milk
Transmission modes
Transmission route
%
Sexual intercourse
80-90
Mother-to-child-transmission
5-10
Blood transfusion
3-5
Injecting drug use
<5
Health care – e.g.: needle stick injury
<0.01
Incidence and modes of
transmission
Summary
 Over the past 2 decades HIV has spread worldwide with
devastating epidemiological consequences particularly
in Sub Saharan Africa
 MTCT is the main mode of transmission of HIV infection
to children
 HIV/AIDS is a major cause of morbidity and mortality.
Unit 2:
Human Immunology &
Biology of HIV
Specific objectives
 Define the cells involved in the immune system and
their function.
 Know the host immune response during and after
infection.
 Basic HIV structure.
 The significance of genetic diversity and classification of
HIV.
 The replication cycle of HIV.
 The target sites for antiretroviral drugs.
Components of immune system
1 Found in blood and tissues
2 White blood cells (WBC)- key players in immune
response (humoral and cellular)
– Macrophages act as clearing cells
– Neutrophils attack bacteria
– Eosinophils attack helminths (and mediate
allergies)
– B-lymphocytes make antibodies
– T-lymphocytes
• Responsible for attacking viruses, fungi and some
bacteria
• T helper cells central in orchestrating function of other
immune cells
• T killer cells are able to destroy infected cells
How HIV affects the immune
system
1 HIV attaches to cells of the immune system with
special surface markers called CD4 receptors
2 Immune cells with CD4 receptors include:
T-helper Lymphocytes
Macrophages
Monocytes
Dendritic cells
Microglial cells
HIV effects on immune system
 The hallmark of HIV/AIDS is profound
immunodeficiency as a result depletion of
CD4+ T lymphocytes.
 The CD4+ T cell dysfunction is two fold
- Reduction in numbers
- Impairment in function
Types of HIV
There are two types of HIV:
HIV-1 (found worldwide and is the main cause of the epidemic)
The strains of HIV-1 can be classified into three groups : the "major"
group
M, the "outlier" group O and the "new" group N. These three groups may
represent three separate introductions of simian immunodeficiency virus
into
humans. Group O appears to be restricted to West-central Africa and
group N
- discovered in 1998 in Cameroon - is extremely rare. More than 90%
of
HIV-1 infections are due to HIV-1 group M. Within group M there are
known
to be at least nine genetically distinct subtypes (or clades) of HIV-1.
These are subtypes A, B, C, D, F, G, H, J and K.
HIV-1 Subtypes
HIV 2
 Found mainly in parts of West Africa, Mozambique and
Angola)
 HIV-2 causes a similar illness to HIV-1including AIDS.
It is however less efficiently transmitted, rarely causes
vertical transmission and is less aggressive, with slower
disease progression.
 In Kenya the commonest type of HIV is type 1 with
Subtype C as the most predominant in eastern Africa.
However other subtypes are also found and recently
HIV type 2 has also been discovered in the country.
HIV 2 cont’d
 Until about 1994, it was generally thought that
individuals do not become infected with multiple
distinct HIV-1 strains. However, it is now thought that
"superinfection" does occur.
 In these cases, the second infection occurs several
months after the first. It would appear that the body's
immune response to the first virus is sometimes not
enough to prevent infection with a second strain,
especially with a virus belonging to a different subtype.
It is not yet known how commonly superinfection
occurs, or whether it can take place only in special
circumstances.
STRUCTURE OF HUMAN
IMMUNODEFICIENCY VIRUS
 Has an outer double lipid
membrane, (derived from the host
membrane).
 The lipid membrane is lined by
a matrix protein.
 The lipid membrane is studded
with the surface glycoprotein (gp)
120 and the transmembrane gp 41
protein.
 These glycoprotein spikes
surround the cone-shaped protein
core.
 The core (capsid) is made up of
several proteins : P24 (the main protein) and P16 P9
and P6 Within the capsid are
two identical single strands of
RNA (the viral genetic material).
Viral enzymes
HIV Replication Cycle
Summary
 HIV attacks the Immune system of human being and
leads to profound immunodeficiency.
 Rapid replication of HIV causes genetic diversity of the
virus.
 Knowledge of the HIV structure is important in
understanding the mechanism of ARV drugs
Unit 3:
Natural Progression of HIV
Objectives
 Describe stages of HIV progression - serocoversion,
asymptomatic, symptomatic and AIDS phases
 Be able to stage HIV infection by WHO classification
Clinical Manisfestations
Acute HIV infection
 Most people infected with HIV do not know that they have
become infected. After the infection; virus is disseminated
via blood to CNS and lymphoid tissue. The Virus trapped in
lymphoid tissue rapidly replicates.
 This is accompanied by patient’s immune response with
concomitant development of antibodies to HIV antigens
usually within 6 weeks, but may take up to 3 months, after
the infection. This “sero-conversion” is when a person
recently infected with HIV first tests positive for HIV
antibodies.
 Some people have a “glandular fever” like illness (fever,
rash, athralgia, fatigue and lymphadenopathy) at the time of
seroconversion.
Clinical Manifestations cont’d
Asymptomatic HIV infection
In adults, there is a long, variable, latent period from HIV
infection to the onset of HIV related disease and AIDS. A
person infected with HIV may be asymptomatic for 2 to 15 years
The vast majority of HIV- infected children are infected in the
peri-natal period. The period of asymptomatic infection is
shorter in children than in adults. A few infants become
ill in the first few weeks of life. Most children start to become
ill before 2 years of age. A number of children remain well for
several years.
Initially CD4 cell levels are high but gradually declines and
immunity starts weakening. The patients are asymptomatic but
are infectious.
Clinical Manifestations cont’d
Progression to HIV disease and AIDS
 As disease progresses without any intervention,
production of CD4 cells cannot match destruction.CD4
cell count decreases and immune system starts failing
leading to increase in viral load. Consequently, there is
increased risk of HIV-related diseases and conditions.
 Almost all HIV infected people will ultimately develop
HIV-related disease and AIDS. Some HIV- infected
individuals progress more quickly than others to HIVrelated disease and AIDS.
 The World Health Organization (WHO) classification of
HIV/AIDS is internationally accepted as the standard
classification, for use in diagnosis and treatment. The
same is shown in the next slide.
WHO Clinical staging
Clinical
stage
Stage I
Selected symptoms
Stage II
1. Weight loss but <10% of body weight
2. Minor mucocutaneous manifestations (seborrhoeic dermatitis,
prurigo,
fungal infections, recurrent oral ulcerations, angular cheilitis)
3. Herpes zoster
4. Recurrent upper respiratory tract infections (e.g: bacterial
sinusitis,
tonsilitis, otitis media, pharyngitis)
1. Asymptomatic
2. Persistent generalized lymphadenopathy
3. Acute retroviral infection
WHO Clinical Staging (Adults) cont’d
Stage III
1. Weight loss: >10% of body weight
2. Unexplained chronic diarrhoea, >1 month
3. Unexplained prolonged fever >1 month
4. Oral candidiasis (thrush)
5. Vulvovaginal candidiasis, chronic (>1 month or poorly
responsive to
therapy)
6. Oral hairy leucoplakia
7. Pulmonary tuberculosis, within past year
8. Severe bacterial infections (eg: pneumonia, pyomyositis)
WHO Clinical Staging (Adults) cont’d
Stage IV
1. HIV wasting syndrome
2. Pneumocystis jerovecii pneumonia (PCP)
3. Toxoplasmosis of the brain
4. Cryptosporidiosis, with diarrhoea >1 month
5. Cryptococcosis (extrapulmonary)
6. Cytomegalovirus (CMV) disease of an organ (other than liver,
spleen, or
lymph nodes)
7. Herpes simplex virus (HSV) infection, mucocutaneous >1
month,
8. Progressive multifocal leukoencephalopathy
9. Any disseminated endemic mycosis (eg: histoplasmosis)
10. Candidiasis of the oesophagus or airways
11. Atypical mycobacteriosis, disseminated
12. Non-typhoid salmonella septicaemia
13. Extrapulmonary tuberculosis
14. Lymphoma
15. Kaposi’s sarcoma (KS)
16. HIV encephalopathy
17. Invasive cervical carcinoma
WHO Clinical Staging (Paediatric)
Clinical
Stage
Selected symptoms
Stage I
1. Asymptomatic
2. Progressive Generalized Lymphadenopathy
3. Hepatospleenmegaly
Stage II
1. Skin conditions
• Herpes Zoster
• Papular pruritic eruptions(PPE)
• Seborrheic Dermatitis
• Fungal nail infections
• Extensive HPV or Molluscum infection (>5% of body area/face)
2. Mouth conditions
• Angular chelitis
• Linear gingival erythema
• Parotid enlargement
3. Respiratory conditions
• Recurrent or chronic URI: otitis media, otorrhoea, sinusitis (>2
episodes/6
months)
WHO Clinical Staging (Paediatric)
cont’d
Stage III
1. Unexplained moderate malnutrition (-2SD or Z score) not
responding to standard therapy
2. Unexplained persistent diarrhea (>14 days)
3. Unexplained persistent fever (intermittent or constant, > 1mo)
4. Oral candidiasis (outside neonatal period 6-8 wks)
5. Oral hairy leukoplakia
6. Pulmonary tuberculosis
7. Severe recurrent presumed bacterial pneumonia (> 2
episodes/12 months, excluding
pneumonia)
8. Acute necrotizing ulcerative gingivitis/periodontitis
9. Lymphoid interstitial pneumonitis (LIP)
10. Unexplained anemia (<8g/dl), neutropenia (<500/mm3), or
thrombocytopenia
(<50,000/mm3) for >1 month
11. HIV-related cardiomyopathy
12. HIV-related nephropathy
WHO Clinical Staging (Paediatric)
cont’d
Stage
IV
Conditions where a presumptive diagnosis can be
made using clinical signs or simple
investigations:
1 Unexplained severe wasting/stunting or severe
malnutrition not adequately responding to
standard therapy
2 Pneumocystis pneumonia
3 Recurrent severe presumed bacterial infections (e.g.
empyema, pyomyositis, bone or joint
infection, meningitis, but excluding pneumonia )
4 Chronic orolabial or cutaneous Herpes simplex infection
(>1 month duration)
5 Extrapulmonary tuberculosis
6 Oesophageal Candida
7 CNS Toxoplasmosis
8 HIV encephalopathy
9 Kaposi's sarcoma
WHO Clinical Staging (Paediatric)
cont’d
Stage IV
Conditions where confirmatory diagnostic testing is
necessary:
10 CMV infection (CMV retinitis or infection of organ other than
liver, spleen, or lymph
nodes onset at age 1 month or more)
11 Extrapulmonary cryptococcosis (incl meningitis)
12 Any disseminated endemic mycosis (e.g. extra-pulmonary
Histoplasmosis,
Coccidiomycosis, Penicilliosis)
13 Cryptosporidiosis
14 Isosporiasis
15 Disseminated non-tuberculous mycobacteria infection
16 Candida of trachea, bronchi or lungs
17 Acquired HIV related fistula
18 Non-Hodgkins lymphoma
19 Progressive multifocal leucoencephalopathy
Summary
 1. HIV targets the CD4 cell
 2. Reduction in number of CD4 cells destroys the
immune system of the host
 3. Patients with low CD4 cells are susceptible to
many infections
 4. All HIV positive patients should be staged as per
WHO classification
Unit 4:
Opportunistic Illnesses
Opportunistic illnesses
(Adults)(1)
HIV RELATED
CONDITION
Acute Bacterial
pneumonia
Pneumocystis
carinii
pneumonia
Pulmonary TB
Toxoplasmosis
Cryptococcal
Meningitis
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
Productive cough, fever, chest
pain,
abnormal chest auscultation
Cough-usually dry, fever,
tachypnoea, cyanosis, chest
auscultation-mostly normal
Clinical and physical
examination. CXR, CBC,
Sputum exam.
High index of clinical
suspicion, CXR- may be
normal Pulse oximetry,
blood gases, BAL
Sputum for AFB, CXR+/-
Antibiotics e.g. Erythromycin
OR Amoxicillin OR
cephalosporin
IV/Oral
cotrimoxazole,supportive
treatment-O2,Prednisolone etc.
High index of clinical
suspicion, CT scan if
available(>/2 ring
enhancing
lesions
Cotrimoxazole (TMP SMX)
TMP 5 mg / kg +SMX 25mg/kg PO or IV
BD-3-6 weeks OR Pyrimethamine-200 mg
loading dose followed by 50mg
OD+Sluphadiazine-1-1.5 gm OD + folinic
acid 20 mg OD
IV amphotericin B 0.7 -1 mg/ kg daily X 2
weeks or until clinically stable, then
Fluconazole 400 mg OD X 8-10 weeks OR
Fluconazole
400-800 mg OD X 10-12 weeks
Cough with or without
hemoptysis> 3 weeks, fever,
weight loss, night sweats
Headache, usually no
meningism,
focal neurological deficit,
confusion, convulsions
Severe headache-can come on
over
weeks, Fever+/-, neck
stiffness+/-,
confusion, convulsions, coma
High index of suspicion,
LPIncreased
ICT(intracranial
pressure),India ink stain
for CSF,CRAG test
RHZE X 2 months then EH x6
months, Add pyridoxine
Opportunistic illnesses (Adults)
(2)
Oesophageal
candidiasis
Oropharyngeal thrush with
painful swallowing,
dehydration, wasting
Clinical diagnosis,
Oesophagoscopy +/-
Fluconazole 200 mg stat, then
100mg OD X14 days OR
Ketoconazole 200 mg OD X 14 days
Oropharyngeal
candidiasis
white plaques in mouth,
palate,
pharynx, erythema
Clinical diagnosis
Topical Nystatin oral drops
500,000 IU QDS/Miconazole
oral gel/tabs, if no response systemic
antifungals
Acute infective
diarrhea
Diarrhoea <2 weeks,
stool examination
abdominal
pain+/-,cramps+/,Dehydration+/Herpes Zoster
Multidermatomal acute,
Clinical
severe painful vesicular
lesions, eye involvement can
lead to blindness, Post
herpatic neuralgia common
CNS Lymphoma Headache, confusion,
CT scan, Biopsy
memory loss,
focal signs without fever
ORS,IV fluids, Antimicrobials (e.g.
Ciprofloxain 500 mg
BDx 10-14 days.
IV Acyclovir 800 mg x5/day- 7-10 days
Analgesics, Calamine lotion. PHN:
Amitryptyline 25-50 mg nocte or
carbamezipine 100mg OD
Systemic che motherapy
Opportunistic illnesses (Adults)
(3)
Papular pruritic
eruptions
severe itching with hyperpigmented,
hyperkeratotic, excoriated papules and
nodules, associated skin thickening &
scarring
Clinical
Chlorhexidine, Cetrimide
ointment, antihistaminics,
ART
Scabies
Cryptococcal
meningitis
very itchy skin, may be treated empirically
Headache, Fever+/-, Neck stiffness
+/-, abnormal gait, confusion,
convulsions, coma
Clinical
High of clinical
suspicion, LP
for india ink,
CRAG
BB lotion, symptomatic
Amphotericin B-gold standard
of treatme nt., IV/Oral
fluconazole, supportive
TB-Pleural effusion Constitutional symptoms, S/S of
pleural effusion
Pleural fluid exam.
For protein s, AFB,
CXR
Anti TB treatment
TB meningitis
Constitutional symptoms, Head
ache, Confusion, Localizing signs
CSF exam. For
Anti TB treatment
protein,
Lymphocytes, AFB,
CT scan
TB
lymphadenopathy
Constitutional symptoms, asymmatrical,
enlarged, matted Lymphnodes
FNA, Biopsy, ZN
stain of aspirate
CandidiasisVaginal
–Not strictly an OI unless chronic
(>1month) or unresponsive to treatment
Anti TB treatment
Anti fungals
Opportunistic Illnesses (Adults)
(4)
HIV RELATED
CONDITION
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
Candidiasis
Oropharyngeal
White pseudomembraneous
plaques, atrophic /erythematous,
angular cheilitis
Clinical by mouth exam
Anti fungals
Candidiasis –
Oesophageal
Oropharyngeal candidiasis with
difficulty and pain in swallowing
Clinical, Endoscopy when
failed emperical treatment
systemic anti fungals
Herpes simplex
Virus
infectiongenital
Red, raisedder vesicles or lesions
Multiple vesicles may
may occur anywhere on the vulva, in occur.
the vagina, or on the cervix or anal
area.
Clinical systemic anti viralsAcyclovir
Kaposis sarcoma
Firm dark purple nodules on skin or Clinical diagnosis
mouth GIT and Lungs, usually not
symptomatic
Chemotherapy,
Radiotherapy,
ART
Cervical cancer
Irregular PV bleeding
Cervical screening, PAP smear Colposcopy, Biopsy
,
Opportunistic illnesses (Children)
(1)
OI/condition
Signs/symptoms
Herpes Zoster Skin: Acute severe pain,
multidermatomal, disfiguring
keloids
Eye: permanent visual loss
Genital: tender vesicles/lesions on
vulva, vagina, cervix or anal area.
May form large ulcers
PTB
Cough > 3 weeks, fever, wasting,
crepitations, effusion
Cryptococcal
Meningitis
Headache, fever, stiff neck
Convulsions, papilledema
Diagnosis
Clinical
diagnosis
Prophylaxis & specific Rx
Severe cases should be hospitalised and
treated, if possible, with IV acyclovir
30mg/kg/day divided into 8 hourly doses for a
total of 7 days, or 2 days after cessation of new
lesion formation, whichever is longer
Pain relief, prevention of secondary bacterial
infection of lesions
Sputum negative Isoniazid 5 – 10 mg/kg/d (max 300mg)
Abnormal CXR
Rifampicin 10 - 20 mg/kg/d
Pyrazinamide 25 – 35 mg/kg/d (2 months)
Ethambutol 15 – 25 mg/kg/d (max 2.5g)
Duration of treatment is according to National
guidelines, but longer courses (9 months) are
recommended for the HIV- infected child Add
prednisone (2 mg/kg OD x 2- 4 weeks) in TBM,
miliary TB, massive pleural effusion and
pericarditis
Clinical
Initial treatment Amphotericin B 0.7-1mg/kg
suspicion key
for 14 days then Fluconazole 3-6mg/kg OD X 8
Raised ICP,
weeks Maintenance treatment (secondary
CRAG
prophylaxis) Fluconazole 3 mg/kg OD for life
Lymphocytosis
LP- Indian ink
Opportunistic Illnesses Children
(2)
Toxoplasmosis
Headache, neurologic deficit,
personality change, blindness,
cerebellar signs
CT Scan >/= 2 ring
enhancing lesions;
Signs of SOL with
relatively normal
CSF
Fansidar
Pyrimethamine 2mg/Kg/day; for 2 days
maximum
25mg, then 1mg/kg/OD three times a week
until 12 weeks beyond resolution of symptoms.
Sulphadiazine 50 mg/kg q12h for 6 weeks
plus
folinic acid 5-20 mg 3 times weekly
Kaposi’s
Sarcoma
Firm, dark nodules, papules, patches
on skin, oropharyngeal, GI, lungs
Biopsy
Chemotherapy + ART
Opportunistic Illnesses Children
(3)
Pneumocystis Usually less than 1 year
jiroveci
Tachypnoea Dyspnoea Low grade
Pneumonia
fever or afebrile Cough
Hypoxemia (paO2 < 90%)
Clinical suspicion key
CXR may be normal
Sputum or bronchial
lavage
Herpes
simplex virus
Clinical diagnosis
based on the typical
appearance of vesicles
and oral ulcers.
Viral isolation
(culture/PCR)
Rising serum HSV
titres and increased
ratio of CSF-to-serum
concentration of HSV
antibody;
Immunofluorescence
staining of fluid
Neonatal infection usually is
disseminated with high case
fatality
Skin or CNS manifestations; may
recur
Oro-labial infection
(gingivostomatitis):
fever, irritability, superficial
painful
ulcers of skin and mucosa. May
extend to oesophageal mucosa
causing difficulty in swallowing.
Encephalitis (>95% type 1
IV Cotrimoxazole Trimethoprim (TMP): 1520 mg/kg/day 6-8 hourly
Sulphamethoxazole (SMX): 75- 100mg
Oral Cotrimoxazole TMP: 20 mg/kg/day 6-8
hourly SMX: 100mg OR
1. IV Pentamidine 4mg/kg/day OD
2. Dapsone 2mg/kg/OD
Course: 2-3 weeks; add prednisone 2 mg/kg
for 7- 14 days in severely ill children
IV Acyclovir 20 mg/kg given 3 times a day
for 21
days for CNS and disseminated disease
For oral 200 – 400 mg 5 times a day for 7-10
days.
Opportunistic Illnesses children
(4)
Cytomegalo virus
Candidiasis
Basic manifestation Congenital: LBW,
hepatosplenomegaly, retinitis,
microcephaly, intracranial
calcifications on skull x-ray or CT
Acquired form:
o Retinitis (presents with visual
problems)
o Meningoencephalitis
o Pneumonia
o Colitis – Abdominal pain and
diarrhea
Clinical
presentation
Fundoscopy
Serology (IgM)
Culture PCR
Histopathology
Ganciclovir 7.5-10 mg/kg/d b.d for 2-3
wks
followed by lifelong maintenance
therapy
Oral thrush
Oesophageal: Painful swallowing,
dehydration, malnutrition, wasting
Endoscopy,
Local treatments (Nystatin, GV)
culture or
Fluconazole 3-6 mg/kg/OD for 2-3 wks.
barium swallow Ketoconazole 5-10mg/kg/in 1or 2 divided
dose
Opportunistic Illnesses children
(4) Cont
Extrapulmonary
TB
Infective
Dermatoses
Bacterial
pneumonia
Hepatosplenomegaly, septic arthritis,
peritonitis
Very difficult to
diagnose
clinically
Therapeutic trial of anti- TB drugs:
RHZE x 2 mos then EH x 6 mos +
pyridoxine Cotrimoxazole prophylaxis
Scabies: papular, itchy rash
Norwegian scabies: extensive skin rash Clinical
with crusting lesions
diagnosis
Papular Pruritic Eruption: itching,
hyperpigmented, hyperkeratotic
excoriated papules & nodules; thick
skin
Empirical trial with BBE at night for 3
nights (itchiness may persist 2 wks)
Fungal infections: Clotrimazole cream. If
severe: Griseofulvin or Fluconazole
Calamine lotion; Steroids last resort
PPE: Chlorhexidine/cetrimide ointment,
antihistamines
Acute, productive cough, fever,
breathlessness
Amoxicillin OR
Erythromycin OR
Cephalosporin
Clinical sign of
consolidation,
CXR
Common infections in children (1)
Illnesses which are common in HIV + as well as
HIV – children
 Respiratory infections
 Diarrhoea
 Measles
 Septicemia, Meningitis
 Skin infections
Above illnesses manifest in more severe forms and
recurrently in HIV + children as compared to HIV children.
Common infections in children (2)
Illnesses which are more prevalent in HIV + children
Tuberculosis
Pneumocystis Jerovecii Pneumonia (PCP)
Oropharyngeal candidiasis
Cryptosporidiasis
Cryptococcal Meningitis
Toxoplasmosis
Herpes simplex virus
Herpes Zoster
Cyto megalo virus
Lymphoid Interstitial pneumonia
Kaposis sarcoma
HIV encephalopathy
Vaccinations
Vaccine
Asymptomatic HIV
Symptomatic HIV
Optimal of timing
immunization
BCG
Yes
No
Birth
DPT
Yes
Yes
6,10,14 weeks
OPV*
Yes
Yes
0, 6, 10, 14 weeks
Measles
Yes
Yes
6 and 9 weeks
Hepatitis B
Yes
Yes
As for uninfected
children
Yellow fever
Yes
No**
Tetanus toxoid
Yes
Yes
5 doses***
WHO/UNICEF Recommendations
 *IPV an alternative for children with symptomatic HIV
 **Pending further studies
 ***5 doses TT for women of children
bearing age
Unit 5
HIV Prevention
Primary prevention Activities
[strategies]
 Behavior change communication.
 Advocacy and lobbying for societal change and
reduction of denial
 Condom promotion and availability
 Sexually transmitted infection management
 Voluntary counseling and testing.
 Prevention of mother to Child Transmission
 Blood Safety
 Stigma Reduction
 Harm Reduction for Injecting drug users
Secondary Prevention
 This includes the management of the HIV positive
person starting to develop HIV/AIDS.
 This is a holistic approach that involves physical, social,
psychological and spiritual interventions.
 The provision of sexually transmitted diseases care.
 The provision of Anti-Retro viral medications.
 Reducing fertility. This alludes to encouraging women
who have the infection not to have children.
 Health promotion strategies must be pursued
aggressively
The ABC of HIV prevention
 A Abstain from sex
 B Being faithful to your partner.
 C Condoms use (correct and consistent use)
 D Discuss about HIV testing
Drugs for STI
Delay sexual début
 E Empowerment in negotiating sex
Adherence to HIV
Therapy
61
Adherence vs. Compliance (1)
Adherence
 The act or quality to stick to something, steady devotion or
the act of adhering.
 It describes the patient’s behavior of taking drugs
correctly; in the right dose, with the right frequency,
and at the correct time.
 A critical aspect of adherence is the patient’s involvement in
deciding whether or not to take the drugs.
[Patients acceptance to take an active role in own health care].
62
Adherence vs. Compliance (2)
Compliance
 The act of conforming, yielding or acquiescing.
 Compliant patients will do what he or she
has been told by the health care provider.
[There is lack of sharing in the decision making].
63
How to Promote Adherence
 Counseling—Very vital
 Participation of the patient in a plan of care. Don’t
rush to ARV, patient must be ready!
 Information/Education/Communication on ARV
drugs:
Provide simple written information
Educate and motivate: basic drug info,
importance of adherence, timing of
medications, drug interactions, etc
Warn patients about common side effects
64
Outcomes of optimal adherence
Positive treatment outcomes.
Slower clinical progression of diseases
 Decreasing viral load.
Economic benefits – Minimal drug.
Resistance  reduced utilization and costs
of drugs and services.
Improving quality of life and therefore
functioning. ( Physical, Psychological, Social etc… ).
65
Predictors of suboptimal adherence;
 Active psychiatric illness (especially depression)
 Active drug and/or alcohol use
 History of non-adherence
 Medication side effects
 Lack of education about treatment.
66
67
Steps Toward Adherence to
Antiretroviral Therapy (ART)
1. Acceptance of ART (Readiness)
2. Ability to take and adhere to ART
3. Maintenance of adherent behavior
68
Factors Affecting Adherence
Disease
Characteristics
Prior OI
Patient/Provider
Relationship
Trust and confidence
Drug related
Number, food/ fluid
restrictions, side-effects,
Pill burden,
Drug interactions,
Storage needs
Clinical
setting
Patient variables
Sex, age, education, alcohol,
social support, readiness
Lifestyle, Socio-Economic, Traveling
Forgetfulness, depression
69
Friendly, supportive
non-judgmental staff
confidentiality, convenient
appointments
Some Barriers to Adherence
Communication difficulties
Low literacy, if written
Unstable living conditions- lack of social support
Discomfort with disclosure of HIV status, which
may became known when medications are taken
 Stigmas, denial and discrimination
 Difficulties in accessing adequate health care




 Competing priorities-
Work, Child care, lifestyle [may be seen as
more pressing than taking medications regularly]
 Alcohol and drug use
 Depression
70
KEY POINTS ON ADHERANCE
ARVs not a cure for HIV/AIDS
Life long treatment.
Taken with specific timing.
Side effects
No sharing of drugs
Appointment dates.
Avoid re-infection
Balanced diet Nutrition
Key points on Adherence
continued
Avoid herbal medication /Treatment,
alcohol, Cigarettes.
Be wise and informed in
faith/miracle/prayer healing.
Disclosure- encouraged for support.
Initiating ARV Therapy (1)
Patients /Guardian involvement in
planning the treatment regimen is critical
Patients Guadian should help in making
final decision of when to initiate ARV
therapy
Initiate ART after counseling has been
given regarding specific issues relevant to
his/her own clinical situation.
73
Initiation of ART in Children
1.An exposed child whose mother is on
ART: At birth, give NVP & AZT syrup
septrin at 6 weeks.
Do a PCR, if NEG, stop AZT and continue
with NVP and septrin if still exposed. If
child turns +ve, start ART.
At 9 months, do an Antibody test, if child
turns +VE, start ART.
TYPES OF HIV TESTING
1.Client initiated HIV Testing &
Counselling. (VCT)
2. Provider-Initiated HIV testing &
Counselling.
3. Other Types- Self Testing,Required HIV
testing eg by Millitary, court of Law.
Other Types of testing continued
In Blood and Tissue Donation
HIV Testing for Research & Surveillance.
LEGAL IMPLICATION ON TESTING
 Supportive documents :
•
Public Health Act,
•
HIV & AIDS prevention and controll Act
(2006 )
• Constitution of Kenya :Bill of rights.
LEGAL IMPLICATION CONTINUED
NB/
All HTC Services should be conducted
with the best interest of the client.
HTC Should never be coercive or
mandatory.
CORE PRINCIPLES TO HTC
• Consent- Should be informed consent.
• Confidentiality – Sharing of information
should only be done with the consent of
the client.
• Counselling – Pre test and post test
counselling.( According to
individual/couple/family needs)
CORE PRINCIPLES TO HTC cont’d:
Consent is based on sufficient, Accurate,
and Voluntary information.
HIV&AIDS prevention and controll Act
provides for testing without consent for
those not able to give consent.
In children, get consent from the
parents/guardians.
CORE PRINCIPLES TO HTC cont’d:
Persons with disability preventing them
from giving consent should be tested with
consent of parents /guardians /
partner/caretaker.
CORE PRINCIPLES TO HTC cont’d:
The only circumstances where consent
for HIV test is not a requirement :
• In requirement for testing under the
provisions of a written law.
• Unconscious patient and unable to give
consent,
• Test medically necessary for a clinical
diagnosis.
STIGMA REDUCTION
 Encourage disclosure.
Psycho- social support eg joining support
groups/clubs etc.
Open group discussions.
Economic support.
Proper counselling- to client and
spouse/caretakers.
Health Education and couselling to
employers,teachers,workplaces etc.
THANK YOU
PREVENTION OF MOTHER TO
CHILD TRANSMISSION OF HIV
BACKGROUND
Over 33 million people are living with HIV/AIDS
worldwide, and about two-thirds or 22.5 million of PLHIV
live in sub-Saharan Africa.
HIV/AIDS mainly affects people of reproductive age and
increasingly affects women, who now account for 69% of
new infections in sub-Saharan Africa, where women are
30% more likely to be living with HIV/AIDS than men, and
young women aged 15-24 are nearly four times more likely
to be infected than their male counterparts.
Young, married women, who are often monogamous, have
become one of the groups most vulnerable to HIV in the
region. This requires new and rapid responses that broaden
the focus beyond traditional “high risk” groups like
commercial sex workers, truck drivers, and drug users.
BACKGROUND cont’d:
To reach young married women, who may not be
aware of their vulnerability, HIV/AIDS prevention,
care and support activities must be integrated into
already established health services that are used by
the general population.
An estimated 370 000 children world-wide became
infected with HIV in 2009, down from a high of
630,000 children in 2003 — most through MTCT.
The risk of an HIV-infected mother passing the virus
to her infant during pregnancy, labour and delivery
or in the postnatal period is 1 in 3 if nothing is done
to reduce this risk.
BACKGROUND cont’d:
Of the one-third who become infected, about 5-10 babies
will be infected during pregnancy, 15 will be infected
during labour and delivery while 5-15 will be infected
during breastfeeding, largely being dependent on
breastfeeding practices and on the duration of breastfeeding.
Most children born with HIV die before they reach their
fifth birthday, with 50% not surviving beyond two years.
ARV prophylaxis pregnancy, labour and delivery and during
breastfeeding period can substantially reduce MTCT.
In resource poor settings, it is critical that prevention
procedures be integrated into existing sexual and
reproductive health (SRH) and maternal and child health
(MCH) services, reaching as many women as possible and
lowering transmission rates.
BACKGROUND cont’d:
 HIV/AIDS transmission from mother to child in Kenya is one of the
biggest health and development challenges in Kenya. According to the
2008/9 Demographic and Health Survey, 6.3% or over 1.4 million
Kenyan adults were living with HIV/AIDS in 2010. There has been
stabilization of HIV sero-prevalence in Kenya. In 2005, the
prevalence rate was estimated at 5.9% and as per the 2006 statistics
the prevalence rate among adults had dropped to 5.1%. According to
2007 Kenya AIDS Indicator Survey (KAIS) the HIV sero-prevalence
in Kenya is 7.8% among adults aged 15-49 years, being higher in
women (8.7%) than in men (5.6%), Young women are more
vulnerable in Kenya than men, as evidenced by a nearly 9%
prevalence rate among women and under 5% among men.
 Infants and young children under 15 years account for 16% of all new
HIV infections mainly as a result of MTCT. Most of the new
infections occur among young people, in whom the main mode of
transmission is through sexual intercourse.
Magnitude of HIV in Pregnancy in Kenya
Kenya National AIDS/STI Control Programme
(NASCOP) estimates that there were 1.55 million
babies born in 2011 in Kenya and that as many as
6.3% of pregnant women in Kenya were living with
HIV/ AIDS.
With an estimated population of 38.6 million in the
year 2010, the number of HIV - exposed babies is
estimated to be 97,272, and at least 38,900 HIVpositive babies are born, assuming a 40 %
transmission without any interventions
Risk of Transmission of MTCT
 In Kenya, an estimated 37,000 to 42,000 infants are infected with HIV
annually due to mother-to-child transmission. This can occur in utero,
during labour and delivery and through breastfeeding.
 During pregnancy, about 5 to 8 percent of HIV-exposed babies
become infected through transmission across the placenta.
 Labour and delivery poses the greatest risk for transmission with 10
to 20 percent of exposed infants becoming infected at this time.
 Breastfeeding also exposes infants to HIV. When mothers breastfeed
for 18 to 24 months another 10 to 15 percent of infants become
infected. Thus, in non-breastfeeding populations, without
antiretroviral treatment, approximately 15 to 30 percent infants will
become infected; with prolonged breastfeeding, 25 to 45 percent
infants will become infected.
Risk factors for MTCT
Strong evidence
Limited evidence
Viral
High viral load
Viral resistance (theoretical possibility)
Viral genotype and phenotype
Maternal
Immune deficiency (low CD4
count), HIV infection
acquired during pregnancy or
breastfeeding period
Vitamin A deficiency, anaemia, sexually
transmitted diseases, chorioamnionitis, frequent
unprotected sexual intercourse, multiple sexual
partners, smoking, injecting drug abuse
Obstetrical
Vaginal delivery (compared to
elective caesarean section),
rupture of the membranes for
more than 4 hours
Invasive or traumatic procedures: instrumental
deliveries, amniocentesis, episiotomy, external
cephalic version (ECV), etc., intra-partum
haemorrhage
Fetal/Infant
Prematurity
Lesions of skin and/or mucous membranes
Breastfeeding
Duration of breastfeeding,
mixed feeding, breast disease
(mastitis/cracked nipples)
Oral thrush (baby)
Benefits of Preventing Mother-to-Child
Transmission of HIV
AIDS related deaths are reversing gains made in
child health and survival in Kenya. Caring for HIVinfected children has major economic and social
impacts on families and health systems.
preventing MTCT has the potential to increase the
understanding and acceptance of the HIV/AIDS
epidemic and those living with HIV/AIDS.
Counseling, testing and community sensitization can
contribute to reducing stigma.
Benefits of Preventing Mother-to-Child
Transmission of HIV cont’d:
Reduction of MTCT of HIV:
- Decreases numbers of HIV infected children
- Increases child health and survival
- Decreases the load on the health system
- Gives an opportunity to improve and expand health
services as well as to strengthen the existing health
infrastructure
Benefits of HIV Counseling and Testing (CT)
It promotes behaviour change
It enables preventive therapy
It promotes access to early medical care
It helps to plan for the future
The Four-Pronged Approach to PMTCT
1. Primary prevention of HIV infection in women
2. Prevention of unintended pregnancy among HIVinfected women
3. Interventions to reduce transmission from HIVinfected pregnant and lactating women to their
children
4. Care and support of women, children and families
infected and affected by HIV and AIDS (The
PMTCT-plus)
Towards virtual elimination of MTCT
(eMTCT)
 elimination of MTCT (eMTCT)- (MTCT rate of <5% among breast
feeding populations or 90% reduction in mother to child HIV
transmission rates by 2015) is now considered a realistic public health
goal and an important contributor to achieving MDGs by 2015
 focuses on prevention of new infections and PMTCT is one of the key
strategies
 focuses attention on the reduction of HIV-related illnesses and deaths,
and mitigation of the effects of the epidemic on households and
communities through key strategic directions namely extraordinary
leadership and commitment, Health systems strengthening including
capacity building for improved access to PMTCT services and
RH/HIV integration.
 Other components include: community systems strengthening,
sustainable financing and regular countdown to track progress.
Towards virtual elimination of MTCT (eMTCT)
cont’d:
 Elimination will mean that MTCT transmission at 18-24 month of
below 5%.
 UN recommends a comprehensive four pronged approach where
elimination targets for each prong have been established. These
include:
- Prong 1; A 50% reduction of HIV incidence among women
- Prong 2; Reduction of unmet need of family planning to zero among
all women
- Prong 3: -reaching over 90% of HIV positive women with More
efficacious ARVs to reduce vertical transmission rate to <5%
- Prong 4: -90% reduction of HIV related maternal deaths up to 12
months post-partum and 90% reduction in HIV attributable deaths
among infants and children<5 years.
Antenatal Care and Prevention of MTCT of HIV
 All pregnant women of unknown HIV status should be offered
opt-out testing at the first ANC visit.
 Repeat HIV testing (After 3 months) in the third trimester
should be offered to all women whose first antenatal test was
performed before 28 weeks gestation.
 Women who decline HIV testing at the first antenatal visit
should have follow up counseling at subsequent visits, and
offered HIV testing.
 Women presenting in labor without documented HIV testing
should have opt-out testing done urgently.
 All facilities providing antenatal and maternity care must have
capability for providing HIV testing at all hours of operation.
 Postnatal HIV counseling and testing should be offered to all
women with unknown HIV status
A rapid HIV testing Algorithm for serial testing.
.
Pre-Test Education
And/or Counseling
First HIV Rapid Test - DETERMINE
Negative Test Result –
Counsel for Negative Result
Positive test Result
Second HIV Rapid Test - UNIGOLD
Positive Test Result –
Counsel for Positive Result
Negative Test Result
Third HIV test – Long ELISA
Positive Test Result – Counsel
for Positive Result
Negative Test Result –
Counsel for Negative Result
Intra-partum Care
Intra-partum care is the management of women from the
onset of labour to delivery.
a) Optimal Intra-partum Care
The following guidelines should be followed for all women
admitted to labour and delivery units
• Minimize vaginal examinations.
• Use aseptic techniques in conducting delivery.
• Avoid routine artificial rupture of membranes (ARM).
• Avoid prolonged labour by use of a partograph.
• Minimize the risk of postpartum haemorrhage.
• Use safe blood transfusion practices.
Intra-partum Care cont’d:
b) Specific Management of HIV Positive Pregnant
Women
Prophylactic Antiretroviral therapies:
The ARV prophylactic regimen depends on whether
the mother had ARVs during pregnancy or not.
Thus, the health care worker should establish the
regimen used during the ANC, whether the woman
had taken ARVs at the onset of labour and determine
the appropriate intra-partum ARV care as follows:
Specific Management of HIV Positive Pregnant
Women cont’d:
i) No ARVs taken in pregnancy
Mother in early labour (up to 1 hour before delivery)
Mother:
 Intra-partum period; Give mother SdNVP 200mg at onset of labour+
AZT 600mg OR AZT 300mg BD + 3TC 150mg BD in labour and
delivery
 Postpartum: Give mother AZT 300mg and 3TC 150mg BD for 7days.
 Assess for ART eligibility and initiate HAART as indicated
Infant:
 Breastfeeding infant
Daily NVP from birth until one week after all exposure to breast milk
has ended
 Non-breastfeeding infant
NVP for 6 weeks
Specific Management of HIV Positive Pregnant
Women cont’d:
ii)Mother received HAART in Pregnancy
• Regardless of duration received HAART (Applies
to both women taking ART and Option B plus)
• Continue the HAART regimen through labour and
delivery and post partum period
• Give infant Nevirapine syrup as above
• Link the mother baby pair to chronic HIV care in the
post partum period
Specific Management of HIV Positive Pregnant
Women cont’d:
iii)Mother received AZT 300mg BD in Pregnancy
Mother: Intra-partum and post-partum period
regimen are same as above
Infant
Breastfeeding infant:
- Daily NVP from birth until one week after all
exposure to breast milk has ended
Non-breastfeeding infant
- NVP for 6 weeks
Specific Management of HIV Positive Pregnant
Women cont’d:
iv) Mother received HAART in Pregnancy
Regardless of duration received HAART (Applies to
both women taking ART and Option B plus)
Continue the HAART regimen through labour and
delivery and post partum period
Give infant Nevirapine syrup as above
Link the mother baby pair to chronic HIV care in the
post partum period
Intra-partum Care cont’d:
c) Mode of delivery
- Elective caesarean section (CS) reduces the risk of
HIV MTCT as compared to vaginal delivery if the
viral load is >1000 copies per ml, but may not be
available in many settings
- Where CS is performed (elective or emergency) in
HIV positive women, prophylactic antibiotics
should be administered
- If the CS is performed after prolonged labour or
rupture of membranes, full courses of antibiotics
should be prescribed.
Use of Antiretroviral Drugs in Pregnancy for HIV Treatment and
Prevention of Mother-to-Child Transmission of HIV Infection
 All HIV-infected pregnant women should be counseled on
comprehensive HIV care including use of ARVs for their own health
and for PMTCT.
 All HIV-infected pregnant women should have their HIV disease
staged using:
- WHO clinical staging (see Appendix 2) and
- Immunological staging (CD4 count)
The women should also be screened and treated for opportunistic
infections (OIs) including Tuberculosis (TB).
 All HIV-infected pregnant women should have baseline laboratory
and other necessary diagnostic evaluations. These should include:
 Routine antenatal care laboratory investigations that are normally
done for all pregnant women (haemoglobin, H.b, rhesus blood group
and ABO typing, VDRL, urine analysis and screening for STI).
 ALT and creatinine levels for women eligible for HAART.
ARV use:
ARVs are used for treating HIV-infected eligible women
and/or for prevention of mother-to-child transmission.
 ARVs for Treatment (ART) & for PMTCT:
- HIV-infected pregnant women eligible for ART should
initiate ART as soon as possible (after adherence
counselling)
- HIV-infected pregnant women already on ART before
becoming pregnant should continue ART.
- Regimen substitution may be necessary in some cases
- Evaluation for treatment response/failure should be done as
soon as feasible
ARV use cont’d:
 ARVs for prophylaxis (PMTCT):
- Mothers who are not eligible for ART (women needing ARV
prophylaxis) should be started on ARV prophylaxis.
- They should be initiated on AZT (300 mg BD) from 14 weeks of
pregnancy or as soon as possible thereafter
- At the onset of labour, give AZT 600 mg PLUS 3TC 300 mg PLUS
NVP 200 mg at once followed by AZT (300 mg BD) and 3TC (150
mg BD) should be for seven days post-delivery.
- Single dose NVP given at the beginning of labour has the ability to
rapidly decrease intracellular and extracellular HIV viral levels and to
act synergistically with AZT and 3TC.
- However, to reduce the risk of development of NVP resistance
following sd-NVP, a 7-day post partum regimen of AZT and 3TC is
given to the mother after delivery. This is called OPTION A of ARV
prophylaxis
ARV use cont’d:
 However, in settings with the capacity to initiate and
monitor triple therapy on HIV infected pregnant
women, triple ARV prophylaxis can be used. This is
called OPTION B. When continued for life without
interruption, it’s called OPTION B PLUS. Due to the
risk of NVP-associated hepatic toxicity in women with
a CD4 count >250 cells/mm, it may be necessary to use
LPV/r-based triple therapy. Emerging evidence has
shown increased morbidity and mortality in patients
who interrupt ART hence women who are initiated on
triple ARV prophylaxis for PMTCT should continue
with lifelong therapy irrespective of CD4 count or
WHO clinical stage or breastfeeding status.
Criteria for initiating ARV treatment (ART) in pregnant
women based on clinical stage and availability of CD4
Count
WHO Clinical Stage
CD4 testing not
available
CD4 testing available
1
Do not Treat
ART if CD4≤350 cells /mm3
2
Do not Treat
ART if CD4 ≤ 350 cells /mm3
3
Treat
ART irrespective of CD4 count.
(Consider CD4 values for better
management)
4
ART irrespective of CD4 cell count
Recommended first-line ART regimen for treating
pregnant women and prophylactic regimen for infants
First line ART regimen for women
Nevirapine exposure within 12 months
Nevirapine exposure >12 months ago OR
No Nevirapine exposure
Preferred
AZT + 3TC+ LPV/r
Alternative
TDF + 3TC + LPV/r
Preferred
AZT + 3TC + NVP/EFV*
Alternative
TDF + 3TC + NVP/EFV*
*EFV should not be used in first 8 weeks (1st trimester) of pregnancy and should be
changed to NVP if in 1st trimester of pregnant.
- 2 NRTIs (AZT and 3TC) acting as a “treatment backbone”, with addition of an NNRTI (NVP) remains the preferred first-line ARV therapy in
resource-poor settings
- Protease inhibitors based regimens are preferable when CD4 count is higher than 250
**EFV may be used instead of NVP after first trimester
Management of HIV and ARV options in Women
with Anaemia
Haemoglobin g/dL
Grade
Remarks
8 - 10
Mild
Look for treatable causes and manage,
Give haematinics irrespective of gestation
6-8
Moderate
AZT contraindicated. Initiate ART irrespective
of CD4 with TDF in place of AZT i.e.
(TDF+3TC+NVP/EFV). Transfuse if >36 weeks
gestation and if <36 weeks gestation give
haematinics
6
Severe
AZT contraindicated. Initiate ART irrespective
of CD4 with TDF in place of AZT i.e.
(TDF+3TC+NVP/EFV).
Transfuse irrespective of gestation
Notes: Important considerations that modify choice of ARVs during pregnancy include CD4
count, maternal anaemia and stage of pregnancy
OPTION B Plus: Alternative Maternal triple ARV
prophylaxis to prevent MTCT
In line with the national PMTCT goal to achieve virtual
elimination of MTCT of HIV by 2015, facilities with ability
to initiate and monitor patients on HAART will be
encouraged to initiate triple ARVs (HAART) for
life(uninterrupted) on all HIV positive pregnant mothers
regardless of their WHO clinical stage or CD4 count in
order to attain maximal viral load suppression
WHO staging and CD4 testing is recommended at baseline
to monitor progress.
Infants born to mothers on HAART would be put on daily
NVP for 6 weeks regardless of feeding option. These
mothers should be enrolled for chronic care and monitored
accordingly.
OPTION B Plus: Alternative Maternal triple ARV
prophylaxis to prevent MTCT cont’d:
The provision of maternal triple ARV prophylaxis
during pregnancy in women who are not eligible for
ART results in very low Utero and peripartum
transmission rates.
A high value is also placed on the simplicity of the
intervention as it contains only one maternal and one
infant regimen and may be available as a once daily
fixed dose combination.
The recommended maternal triple ARV regimens for option B plus include
TDF+3TC+EFV, AZT+3TC+EFV, AZT+3TC+LPV/r, AZT+3TC+ABC. Nevirapine
based regimens are not recommended because of the risk of hepatotoxicity for women
with high CD4 counts(>250 cells/mm).
Why option B plus and not Option B
Emerging evidence show that Non ART eligible
women started of Triple ART followed by
interruption leads to deterioration with morbidity
and mortality*
 Other evidence suggests that most women Not
eligible for ART during pregnancy will become
eligible anyway within a period of 2 years.
Benefits of option B plus:
For regimen simplicity. No Staging or CD4 testing.
(Although CD4 counts or viral load assays are still
desirable for determining baseline immunological
status and monitoring)
 Extended protection from mother-to-child
transmission in future pregnancies from conception
 A strong and continuing prevention benefit against
sexual transmission in sero-discordant couples and
partners likely benefit to the woman’s health of
earlier treatment and avoiding the risks of stopping
and starting triple ARVs, especially in settings with
high fertility.
Infant Nevirapine Prophylaxis for HIV Exposed Infants
Age
Nevirapine Dose
0 – 6 weeks
Birth weight < 2500 g – 10 mg (1 ml) once daily
Birth weight > 2500 g – 15 mg (1.5 ml) once daily
6 weeks – 14 weeks
20 mg ( 2 ml) once daily
14 weeks to 6 months
25 mg (2.5 ml) once daily
6 months – 9 months
30 mg (3 ml) once daily
9 months – 12 months
40 mg (4 ml) once daily
> 12 months
50 mg (5 ml) once daily
NOTE:
• AZT 15mg/kg twice daily is an alternative for
infants on TB treatment or NVP toxicity
• 3TC is an alternative for infants with severe
NVP toxicity (grade 3 or 4)/or if baby is on TB
treatment with rifampicin containing regimen
Infant Lamivudine prophylaxis for infants who
cannot take NVP
Age
Dosage
0-4weeks
2mg/kg twice daily
>4 weeks
4mg/kg twice daily
Infant AZT prophylaxis dosage for HIV exposed infants
Birth weight
Dosage
<2500g
10mg/kg twice a day
>2500g
15mg/kg twice a day
Immediate Postnatal and Neonatal Care
Immediate postnatal and neonatal care refers to the
package of services provided to the mother and
infant before they leave the health facility (up to 48
hours) after delivery.
The period provides an opportunity to educate all
mothers on optimal postnatal care including HIV, to
provide HIV counselling and testing if it was not
done previously, and to reinforce the education
provided during the antenatal period.
Both HIV infected and HIV uninfected mothers
should receive this education and counselling before
discharge.
Immediate Postnatal and Neonatal Care cont’d:
The following guidelines should be followed for all women and
infants in the immediate post partum period:
a) Optimal postpartum care
 Support infant feeding options. For all HIV negative women, women
of unknown HIV status and HIV positive mothers opting for exclusive
breastfeeding, initiate breastfeeding within half hour of birth and
follow other guidelines as per Baby Friendly Hospital Initiative
(BFHI).
 Package of services provided to mothers and neonates within first 48
hours after delivery
 Services targeting HIV infected and HIV uninfected mothers would
include:
 Health education on maternal nutrition; Advice on danger signs
(mother and newborn), emergency preparedness and follow up; care
of the newborn Following the standard guidelines on the care of a
newborn
Immediate Postnatal and Neonatal Care cont’d:
Optimal postpartum care cont’d:
 Identification of complications in mother and newborn - manage
and/or refer appropriately
 Routine postpartum care: blood pressure measurement; breast
examination; examination of the uterus, the perineum and lochia.
Ensure regular passage of urine and proper hygiene to prevent
infection; checking for signs of anaemia, fever and tachycardia and
Vitamin A supplementation
 Establish the HIV status of all postnatal mothers including those who
delivered outside the health institution setting; Provide HIV testing
and counselling for mothers with unknown HIV status and all those
who tested negative and did not get re-tested in the antenatal period;
Encourage HIV results disclosure and partner testing.
 All babies should receive their routine immunization (OPV and BCG)
in their first hours of life.
Immediate Postnatal and Neonatal Care cont’d:
b) Specific postpartum care for HIV positive women:
 Support exclusive breastfeeding (with cover of ARVs)
until six months unless the mother has been counseled
on replacement feeding and meets the AFASS criteria.
 Initiate/continue Cotrimoxazole for all HIV positive
women
 For the newly diagnosed, perform WHO Staging, CD4
Count and treat/refer for ART appropriately.
 For mothers on ART/HAART; continue with treatment
Immediate Postnatal and Neonatal Care
cont’d:
c) Specific care for HIV exposed infants:
Initiate Nevirapine syrup prophylaxis
Counsel/provide infant feeding options
Late Postnatal Care and Family Planning
 Late postnatal care is provided to the mother and the child 48
hours to 6 weeks after delivery. During this period, the health of
the mother and child is assessed and closely monitored.
 The risk of MTCT during the postpartum period can be reduced
by providing HIV counselling and testing, ARV prophylaxis to
the mother or exposed babies, counselling on appropriate infant
feeding options and breast care.
 Postpartum care for HIV positive women should include clinical
staging, CD4 count and ART for those who qualify.
 Family planning services are among the core interventions of
PMTCT provided to help women determine future childbearing
patterns including the prevention of HIV-infected births.
 Reproductive health counselling can help a woman practice safer
sex and determine her future childbearing patterns on a more
responsible and informed basis
Optimal postpartum care for all women
This entails routine postpartum care including;
 Breast examination, examination of the uterus, examination
of the perineum and lochia, passage of urine regularly,
proper hygiene to prevent infection, checking for signs of
anemia, fever and tachycardia and advice on doing perineal
exercises.
 Counselling and testing for mothers of unknown HIV status
and for those who tested negative during early antenatal
period.
 Counselling on maternal nutrition; infant feeding options,
risk reduction; hygiene, breast care and dual protection
 Provision of condoms and initiation of viable method of
contraception;
Routine postpartum care cont’d:
- Screening for STI s and Cancer of the Cervix at 4-6
weeks
- Counselling on post-partum danger signs in the
mother and appropriate action
- Counselling on avoidance of penetrative sex until
there is no lochia.
- Counselling on Malaria prevention
- Care and support for the mother – partner support
and linkage to psychosocial support groups
- Initiation of care and treatments as per national ART
guidelines.
Optimal postpartum care for HIV positive
women
i) Breast care in breastfeeding mothers:
Should wear a good supporting brassiere day and
night.
 Whenever breasts are engorged, ask the mother to
express to comfortable level (not emptying breast).
 Give analgesics for pain.
 Initiate contraception within 4 weeks of delivery
Optimal postpartum care for HIV positive
women
ii) Lochia:
Put emphasis on good perineal hygiene and proper
handling of body fluids.
 Avoid contaminating the baby with body fluids or
with bedding soiled with lochia.
 Sharing of beds by mothers in the hospital should
be discouraged.
Optimal postpartum care for HIV positive women
cont’d:
iii) Caesarean Section:
- Broad spectrum antibiotics should be used routinely after
CS.
Essential maternal education and follow-up:
Monitor for breast and pelvic infection at all post natal
clinic visits.
 Educate on prompt health seeking behaviour.
 Health education on hygiene, lochia and breast care.
 Avoid sexual intercourse for at least 2 weeks after birth or
until there is no longer any lochia rubra or serosa.
 Do pap smear or VIA at 4-6 weeks.
 For every sexual activity, the couple should use condoms.
Optimal postpartum care for HIV positive women
cont’d:
Contraception
Persons living with HIV and AIDS have been shown to
have a higher (over 50%, KAIS 2007) unmet FP need as the
non-infected (26%, KDHS 2008/9)) persons.
FP service providers must ensure that safe and effective
contraception is accessible to women who are HIV positive
in order to help them not only plan their future child bearing
patterns but also to prevent the births of HIV positive
children.
All mothers, regardless of their HIV status, have a right to
receive adequate information on available methods of
family planning and to make an informed choice on what is
best for them.
Contraception cont’d:
With very few exceptions, all methods of
contraception can be used by HIV positive women
based on standard medical eligibility criteria
including taking care of drug interactions
All FP clients regardless of their status, should
receive counseling about dual protection including
Dual method use with emphasis on the importance
of correct and consistent use of condoms
Contraception cont’d:
Lactational Amenorrhoea Method (LAM):
- Suitable for exclusively breastfeeding HIV infected
women who have not resumed menses
- For HIV positive women, dual method contraception
is advised.
Contraception cont’d:
Hormonal contraception:
- All hormonal contraceptives can be used in HIV
positive women including those on HAART.
- Combined oral contraceptives may be
contraindicated for use with drugs that induce
hepatic micro-enzyme that may reduce the
effectiveness of hormonal contraceptives: Included
in this group, are some anti-TBs, some
antiretrovirals, antifungals and anti-epileptics, and in
conditions that cause malabsorption.
Contraception cont’d:
Intra-uterine contraceptive devices (IUCDs):
- IUCDs are not contraindicated in HIV positive
women.
- In severely immuno-suppresed women, IUCD use
should not be discontinued but new insertion is
discouraged as it may be associated with increased
risk of infection during the insertion process.
- However, the IUCD may be inserted once the client
is put on ARVs and is doing well on them
Contraception cont’d:
Surgical methods:
- Surgical contraception should be offered to HIV
positive women and their partners.
 Barrier methods:
- Female and male condoms provide protection against
STIs and reduce the risk of HIV transmission and
should be encouraged alone or preferably used
together with other more effective contraceptive
methods to what is referred as Dual method use
Contraception cont’d:
Emergency contraception:
- EC is a safe and effective way to prevent pregnancy
after unprotected intercourse.
- It can be started up to five days (120 hours) after
unprotected intercourse.
- should not be used as a regular contraceptive
method.
- can be used by HIV positive women.
- HIV positive women should be informed about
emergency contraception, where it is available, how
to access and use it.
Contraception cont’d:
Fertility Awareness Based method:
- Women who are HIV-positive who may or may not
have AIDS and those on ARV therapy can use FAB
methods without restrictions
- women who want to use the Standard Days Method or
Calendar method should have regular menstrual cycles
- Women and couples relying on FAB methods should be
counseled that they are not protected from STI and HIV
transmission and should be encouraged to use condoms
even on days when risk of pregnancy is low.
Care, support and treatment for HIV positive
mother and child
HIV-positive mothers require care and support which
includes:
• Counselling.
• OI prophylaxis and treatment.
• Link to support groups and assessment of the need
for ART.
• Early infant diagnosis (EID) should be provided at
six weeks and thereafter using EID algorithm
Thank You!
HIV Diagnosis in Children
- Early infant diagnosis (EID) refers to the making of
HIV diagnosis in infants and young children before
18 months of age.
- EID gives an opportunity for early identification of
HIV exposed and infected infants (due to suboptimal PMTCT service or lack of it)
- early linkage to prevention for the exposed and care
and treatment for the infected
- disease progression in HIV infected infants is fast,
with a high mortality rate (> 50%) by 2 years of age.
HIV Diagnosis in Children cont’d:
- HIV antibody testing among children aged 18
months or more is able to determine whether a child
is infected or not
- During pregnancy, there is transplacental transfer of
HIV antibodies to the unborn baby from the mother,
these antibodies disappear with time from the
infant’s blood.
- Antibody testing in children aged less than18
months identifies children who have been exposed
to their mothers’ HIV infection or who may be truly
infected and are making HIV antibodies.
HIV Diagnosis in Children cont’d:
- Currently, there is no test to differentiate
the mother’s antibodies from those
produced by the baby.
- In order to identify the HIV-infected child
aged less than 18 months, a second test
is required for all babies testing positive
on antibody testing or known to be HIVexposed (mother is HIV-positive).
- Infant DNA (or RNA) PCR testing is the
current recommended method for EID.
HIV Diagnosis in Children cont’d:
- Since most babies loose maternal antibodies (Ab) by 9
months, a negative antibody test will identify uninfected
babies as long as they are not breastfeeding
- A positive antibody test at >9 months, although highly
likely to be diagnostic, may still be due to passively
carried maternal antibodies
- A confirmatory PCR test should be done for all positive
antibody tests before 18 months of age.
- An antibody test at /after 18 months of age is
confirmatory of HIV infection in HIV exposed infants.
Guidelines for HIV diagnosis in
children
• Perform routine rapid HIV antibody tests for all mothers or infants
presenting with unknown HIV status to establish exposure status of
the infants.
• Perform routine dry blood spots (DBS) for DNA PCR for all infants
known to be HIV-exposed at 6 weeks or at first contact thereafter
• Perform routine antibody testing for all sick infants in outpatient and
paediatric wards to establish HIV exposure/infection status.
• Perform a confirmatory DNA, PCR test for all HIV-exposed sick
infants with a positive antibody test before 18 months of age.
• All HIV-exposed infants should be started on co-trimoxazole from 6
weeks of age or on first contact thereafter.
HIV negative infant at age 6
weeks or first contact
• Perform antibody testing at 9 months and 18 months
of age.
• If HIV negative at 9 months and still breastfeeding,
continue cotrimoxazole and repeat Ab test at 2
months after cessation of breastfeeding or at 18
months whichever comes first.
• If HIV antibody test is positive before 18 months
perform a confirmatory DNA PCR test.
• If NOT breastfeeding for at least 2 months and HIV
test is negative, stop co-trimoxazole.
• Perform confirmatory antibody testing at 18 months.
HIV positive infant by DNA PCR
• All HIV-positive infants should be started on HAART ,
regardless of their WHO stage , CD4 count or CD4%.
• However, WHO clinical staging and CD4 count/percentage
should be done for all HIV positive infants as a baseline.
• All HIV-positive infants should have a visible guardian or
care-taker before they can be started on ART to assure
adherence.
• All HIV positive infants should be started on Cotrimoxazole
from 6 weeks or on first contact thereafter.
• Breastfeeding should be encouraged for all infants who test
HIV-positive for a minimum of one year.
All HIV positive infants should be started on HAART regardless of WHO
stage or CD4 count or %.
Comprehensive care for HIV-exposed
children:
Both HIV-infected and uninfected children
require comprehensive care
Feeding Infants and Young Children
Born to HIV Infected Mothers
Transmission of HIV through Breastfeeding
In Africa, 3 to 4 out of every 10 infants born to HIV
infected women acquire HIV infection.
Use of ARVS either for the mother or the infant
significantly reduces the risk of HIV transmission
from the mother to the child
Exclusive replacement feeding if done appropriately
reduces the risk of HIV transmission but hygiene
should be observed to avoid the morbidity and
mortality associated with it.
Feeding options for a HIV exposed infant
1. Exclusive breastfeeding with ARVS
2. Exclusive Replacement feeding
Operational Guidelines on Infant feeding (0-6
months)
- All mothers who are HIV negative or are of
unknown HIV status should be encouraged and
supported to exclusively breastfeed for the first 6
months and continue breastfeeding with appropriate
complementary feeding introduced thereafter.
- All HIV positive mothers should be given
information on available infant feeding options and
counseled using recent scientific information on
benefits and challenges for each option in order to
help them make an informed choice.
Operational Guidelines on Infant feeding (0-6
months) cont’d:
- All HIV positive mothers who choose to breastfeed
should be encouraged and supported to exclusively
breastfeed for the first 6 months and continue
breastfeeding up to 1 year with appropriate
complementary feeds. Infants of these mothers
should be provided with nevirapine prophylaxis for
up to 1 week after complete cessation of
breastfeeding.
Operational Guidelines on Infant feeding (0-6
months) cont’d:
- HIV positive mothers who choose not to breastfeed
and meet AFASS criteria should be encouraged and
supported to do exclusive replacement feeding for
the first six months and appropriate complementary
feeding introduced thereafter. Infants of these
mothers should be provided with nevirapine
prophylaxis for 6 weeks.
Operational Guidelines on Infant feeding (0-6
months) cont’d:
- In special circumstances determined by clinicians
involving infants who cannot breastfeed e.g. orphans
or abandoned babies or where the mother has
conditions like mastitis preventing breastfeeding, the
infant should be provided with exclusive
replacement feeding with appropriate
complementary feeds introduced thereafter.
Operational Guidelines on Feeding Children 6
months and older
- Complementary foods should be introduced with continued
breastfeeding or with replacement feeding until a
nutritionally adequate diet can be sustained without milk.
- For HIV exposed infants, continued ARVs for the infants
should be provided up to complete cessation of
breastfeeding.
- Abrupt cessation of breastfeeding is NO longer
recommended as this causes psychological trauma for both
the mother and the baby.
- From 6 months animal milk can be introduced and should
continue as an important component of the child’s diet.
- Complementary foods should be prepared from locally
available family foods.
Nutritional Care and Support of HIV infected
children
Energy needs for asymptomatic HIV infected
children increase by 10 percent to maintain growth
as compared to the non-infected children while for
symptomatic HIV infected child this increases by
50-100%
There is no evidence of increased protein
requirements. The requirements should be based on
individual symptoms and needs.
Micronutrient requirements do not change.
Extracts from Research on Infant Feeding and
HIV/AIDS
Evidence available from current research data shows that:
• Increased risk of mortality with replacement feeding is significant.
• HIV free survival rate at 18 months of age does not significantly vary
between an exclusively breastfed and exclusively replacement fed
child.
• Modified animal’s milk is no longer recommended for children less
than 6 months of age.
• Abrupt cessation of breastfeeding is no longer recommended.
• Therefore, exclusive breastfeeding (With ARVs) up to 6 months is
recommended unless a mother chooses replacement feeding and can
meet AFASS criteria.
• If breastfed infant is given solid foods (Mixed fed) before 6 months, the
risk of HIV infection is eleven times as high as the exclusively
breastfed infant.
Care and Follow-up of Children of HIV-infected
Mothers
The following guidelines should be followed in the care and
follow-up of children of HIV-infected mothers:
- All HIV exposed infants should be seen in the health care
facility within two weeks of delivery.
- For all HIV exposed infants, monthly follow up visits are
recommended beginning at six weeks through 2 years.
- Where possible, visits should be linked to the immunisation
and growth monitoring visits.
- All HIV exposed infants should be started on co-trimoxazole
prophylaxis from 6 weeks of age.
Care and Follow-up of Children of HIV-infected
Mothers cont’d:
For infants who test HIV negative:
- If they have stopped breastfeeding for 2 months or
more, stop co-trimoxazole
- If still breastfeeding, confirm status after stopping
breastfeeding. Co-trimoxazole should be continued
until two months after complete cessation of
breastfeeding.
For infants who test HIV positive by DNA PCR
before 18 months or by antibody test after 18
months of age, co-trimoxazole should be given
daily for life.
EARLY INFANT DIAGNOSIS OF HIV
Dried Blood Spot Collection
and Handling
Sample Collection
o Having a good test kit is not enough guarantee to
obtaining reliable results
o Valid and reliable results depends a great deal on
quality samples
o Proper sample collection technique play a vital role
in quality of results issued
166
Blood Collection Requirements
S&S 903 filter papers
Drying rack
Blood collection tubes
Capillary tubes/pipettes
Gloves/Gown
Lab register
Zip- lock bags
Glassine bags
167
Requirements for DBS Preparation
Pipette
Blood Samples
Pens
Cotton gauze
Humidity indicator
cards/Desicants/Zip lock
bags/Filter papers/Wax
Paper
Gown
SOP’s
Sharps
container
Solid waste
Drying Rack
Gloves
168
Disinfectant
What Are DBS Collection Cards?
NAME: ________________________
DATE: ________________________
 These are not ordinary blotting papers. They are used for
different purposes e.g. antibody detection, PCR etc.
 The paper matrix characteristics involve density,
absorbance, etc
 This ensures that you have a specific volume of blood
169
within the circle.
Advantages of DBS
Easy collection
Simple transportation
Easy and compact storage
Safer to handle
Testing can be performed centrally
Archiving easy
Impregnated chemical formula to preserve the
protein
Stabilize the protein for longer storage at RT
Preserve against oxidation
170
Handling of Filter paper
Use universal safety procedures
Use finger/ heelstick procedure
Use powder free gloves
Label the filter paper while avoiding
contamination
Place labeled filter paper on drying rack
Apply two(2) drops of blood to each circle
Allow blood to dry overnight in free air
circulation
171
S & S 903 Filter Paper
[Client code]
NAME: ________________________
[Date]
[Counselor code]
DATE: _________________________
172
Choosing where to stick
Infants age 1-4 months, less than 6kg heels work
best
Infants age 5-10 months, less than 10kg toes work
best
Larger infants use finger
173
Procedure for DBS collection
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Warm the area
Position baby with foot down
Sterilize area with alcohol
Allow to air dry
Press lancet into foot, prick skin
Wipe away first drop
Allow large drop to collect
Put 50mL into each circle
Fill at least 3 circles
Clean foot, no bandage
Dispose of all contaminated
material
2nd choice
1st choice
174
Finger stick
Procedure
Label the test devices
Sterilize site with an alcohol or spirit swab
Allow alcohol to air dry
Perform finger stick (skin puncture)
Wipe out first drop of blood with dry cotton
wool
Collect drops of blood using a pipette
Stop the bleeding using dry cotton wool
Dispose of all contaminated materials
175
Dry Completely Before Packaging
176
Drying DBS
Don’t touch or smear the blood spots
Allow the blood to air dry horizontally for at
least 16 hours
Keep away from direct sunlight, dust, and
bugs
Do not heat, stack or allow DBS to touch
anything during the drying process
177
Quality DBS SAMPLES
178
NAME:
10105003
DATE:
20/10/2005
008
Packaging and Storage of DBS
 Ensure the blood spots are completely dry
 Insert each filter paper into a small zip lock bag
 Insert a desiccant from the Uni-Gold or Bioline used
test kits
 Expel as much air as possible and seal the bag
 Store at room temperature
 Submit week’s collection to the reference
Laboratory accompanied by standard LRF
179
Storage of DBS
Store DBS in zip-lock bags with desiccant at RT for
30days
Store DBS at -4oC for up to 90 days
For longer storage, store DBS at -20oC
180
DBS SUBMISSION FORM
Site Name__________________ Site Code___________
Testing site in-charge-(name)___________ Sign_______
Supervisor-(Name)__________________ Sign________
Date of Visit ___________________________________
Serial
No:
DBS Identification
No.
DBS date of
collection
Reference
Lab. Name
Remarks
1
2
3
etc
181
Rejection Criteria for DBS
Over saturation
Insufficient blood
Scratched spots
NAME: _________________________
Scattered spots
DATE: _________________________
Two layer spots
Serum rings – water, alcohol, horizontal plane
Clotted blood
Improper drying
Spots that cannot elute
182
MINISTRY OF HEALTH
ALGORITHM FOR EARLY INFANT DIAGNOSIS FOR HIV EXPOSED CHILDREN
SICK CHILD
WELL CHILD
(Manage presenting illness and stabilize)
START COTRIMOXAZOLE PROPHYLAXIS, AB TEST TO INFANT IF EXPOSURE NOT KNOWN
6 WEEKS DBS (PCR)
If <18 months DBS (PCR*)
HIVHIV+
HIVHIV+
Counsel for exclusive BF and
early weaning at 6 months
Evaluate for ART
start on ARV if Eligible
Antibody testing
9 and 12m
If HIV-ve stop CTX, if not
B/F for at least 3 Months
If HIV+ at 12 m
Evaluate for ART
start on ARV if Eligible
Confirmatory AB test
at 18m
Evaluate for ART
start on ARV if Eligible
Continue child welfare services.
If still breastfeeding counsel for
exclusive BF and early weaning
at 6 months
Antibody testing
9 and 12m
If HIV+ at
12m
Evaluate for ART
start on ARV if Eligible
If HIV-ve stop CTX, if not
B/F for at least 3 Months
Confirmatory AB test
at 18m
FOR MORE INFORMATION CONTACT THE NATIONAL AIDS/STD CONTROL PROGRAMME (NASCOP)
P.O. BOX 19361-00202 NAIROBI TEL: 0202729502 FAX 020 2710518
The network-how it works
Packaging
1 day
Sample
Collection
ART/PMTCT
centre
4 days
Training
• Collection of DBS
• Logistics of sending DBS
• Materials given for DBS collection
Securicor
Samples
1 day
Testing labs
Securicor
Results
D
D / M
M /
Y
Y
Chemistry
Viral Load
CD4
(purple tube)
Infant PCR
HIV Elisa
#
(purple tube)
#
Heamatology
Date:
#
(purple tube)
Patient ID
(lavender tube)
Number of Samples:
(red - plain tube)
LABORATOIRE NATIONAL DE REFERENCE
HIV SAMPLE SUMMARY FORM
Site Name:
(red - SST tube)
5 days
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Clinic Signature:
Lab Signature:
Clinic Initials:
Lab Initials:
1 day
PROCEDURE OF PERFORMING DBS
Warm the area
186
Put on gloves, wash off glove powder
187
Position baby with foot down
188
Clean the area, dry 30 seconds
189
Press lancet into foot, prick skin
190
Wipe away first drop
191
Clean area, leave with no bandage
192
Done! Let’s do another one!
193
Warm the area
194
Position baby with foot down
195
Clean area, dry 30 seconds
196
Press lancet into foot, prick skin
197
Wipe away first drop
198
Job well done
199
Keep requisitions with DBS cards
200
2. Insert Into Sealable Plastic Bag
201
3. Add Desiccant Packets
Minimum 10 packets per bag
202
4. Add Humidity Cards and Seal Bag
203
How to Store DBS
Keep packaged DBS (in sealable plastic
bags) refrigerated until transported to
reference laboratory
Avoid leaving in vehicle,
as sun and heat will
deteriorate DBS
204
How to Package DBS for Shipping
1. Insert into envelope
2. Include lab
requisitions
3. Include specimen
delivery checklist
4. Label outside clearly
5. Send to BHP lab
205
The Dont’s
206
207
208
209
210
Note blood drops too small with toe
squeeze
211
Laboratories performing PCR
 Kisumu KEMRI/CDC
o 200 samples a week
o Nyanza/Western/Rift Valley
 Kericho KEMRI/Walter Reed Project
o 100 samples a week
o Southern Rift
 Nairobi KEMRI/CDC
o 48 samples a week
o Central/Eastern/Coast/Nairobi
 MTRH- Ampath program
o Capacity not known
o Serves Northern Rift
212
Recording PCR tests
Date
Collected
Patient
ID
Collected
by
Date
sent
Date
Results
Received
• Other details to record



213
Who requested the test?
Location of client (Ward, MCH)
Client’s next visit
Received
by
RESULT
Cost of Testing
Approximate cost/test
Cost of Test CIF Nairobi
$10
Clearing & 2.75% IDF fee
$3.25
Laboratory consumables
$1.2
Filter paper & packaging
$1.25
Transportation (5 per package)
$0.3
Total
$16
Approximately Ksh 1,200/= per test
(without cost of lab human resources)
214
The end
Q & A?
215