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Pediatric Case
Presentation
Irma L. Febo M.D.
Associate Professor
University of Puerto Rico
School of Medicine
Disclosure of Financial Relationships
This speaker has no significant financial
relationships with commercial entities to
disclose.
This speaker will not discuss any off-label use
or investigational product during the program.
This slide set has been peer-reviewed to ensure that there are no conflicts
of interest represented in the presentation.
Present Illness
• Case of a 16 year/old Hispanic male without
history of any chronic condition.
• He developed a severe headache associated
with general malaise and was evaluated at
Emergency Room.
• He was found to have lymphopenia and
thrombocytopenia.
• A CT Scan of head showed an intracranial ring
enhancing lesion in right cerebellar area with
edema. No hemorrhage or calcifications. No
fractures observed.
• CNS Toxoplasmosis infection was suspected.
Toxoplasma IgG level was high, with negative
IgM.
• Cytomegalovirus IgM was negative.
• HIV-1 antibody test was reactive, with positive
Western Blot.
• HIV viral load showed 260,323 copies/ml.
• Absolute CD4 count: 5 (1%).
• He was admitted to Intensive Care Unit due to
cerebral edema.
• He was started on Pyrimethamine,
Clotrimazole, Sulfadiazine, Leukovorin,
Decadron and Clindamycin.
• After two weeks of treatment, he showed
complete recovery and no further signs or
symptoms.
• Follow-up MRI showed resolution of brain
edema and no evidence of Toxoplasma lesion.
• He was discharged home to be followed as
outpatient at the Pediatric HIV Clinic.
Past History
•
•
•
•
•
No allergies.
No prior admissions to Hospital.
No blood transfusions.
No drug use.
Reports to be heterosexual, sexually active
with two female sexual partners. Started
sexual activity at 14 years/old, with frequent
use of condoms.
• No tattooing, no body piercing.
• Normal growth and development for age.
Perinatal History
• Born to a 28y/o G2A0P1 mother, who had
prenatal care since first trimester. No history of
alcohol or drug use.
• Mother refers she had one negative HIV test at
the first trimester, and no evidence of a second
HIV test during pregnancy.
• No complications during pregnancy, and born
by spontaneous vaginal delivery at term.
• No complications in nursery.
• No history of breast feeding.
Family History
• Father died of AIDS when the child was
5 years old.
• Mother diagnosed with HIV infection
when he was two years old.
• He had an older brother with congenital
neurologic condition.
• No other major medical conditions in the
family.
Social History
• He lives with his mother, brother and
maternal grandfather.
• He had normal growth and development.
• At the time of his diagnosis, he was
finishing 11th grade of High School.
• He likes to play basketball and has many
friends.
• No history of depression or use of illegal
substances.
Physical Exam
• General appearance: Low weight adolescent
(10th percentile), alert, well developed
• HEENT: Teeth with multiple cavities, oral thrush
lesions; normal fundoscopic exam
• Neck: No lymphadenopathies
• Lungs: Clear to auscultation
• Heart: Regular rhythm, no murmurs
• Abdomen: No tenderness, no visceromegaly
• Genitalia : No lesions, normal male, Tanner IV
• Skin: No lesions
• Neurologic: No deficits
Assessment
• HIV infected adolescent with AIDS, a
high suspicion of being vertical
transmission.
• Cerebral Toxoplasmosis
• Oral Candida
• Dental Cavities
• Disclosure of diagnosis given by
Pediatric HIV Clinic Psychologist.
Follow up
• At the outpatient Pediatric HIV Clinic he
was started on ART with
efavirenz/emtricitabine/tenofovir
co-formulated tablet once a day, along
with his Toxoplasma maintenance
treatment.
• He was also started on PCP and MAC
prophylaxis.
Follow up
• After one month on his Highly Active
Anti-retroviral treatment (HAART) his
HIV viral load was undetectable.
• After two months of HAART his CD4
count increased to 70 (8%).
• The patient was asymptomatic, and he
returned to school and resumed his
normal life.
Virologic failure
• Six months after the initiation of therapy he
showed virologic failure with HIV viral load
of 36,850 and decrease of CD4 count to 23
(4%). The virologic failure was confirmed
with a second determination showing viral
load of 118,209.
• He admitted to being non-compliant with
HAART.
• HIV Genotype showed resistance to
efavirenz and nevirapine (mutations g190a,
k103k/n, p22h/p, v179d). No resistance
to NRTIs or PIs.
Treatment
• HAART regimen was changed to
atazanavir, ritonavir, and co-formulated
emtricitabine/tenofovir.
• Although treatment changed, he
persisted with high viral load and severe
immunosuppression.
• He was otherwise asymptomatic. He
finished high school and started junior
college.
• He didn’t want to take his medications.
• He expressed that he understands his
diagnosis and the importance to continue
his treatment, but that now he feels
better, and that it is difficult to take the
medications every day.
• He had been referred for psychological
therapy to work on his adherence
problem.
Important points of discussion
• Apparently, this case represents a missed
opportunity to diagnose this child earlier in life.
• Although he was completely asymptomatic, both
his parents showed HIV infection during his
childhood. Remember to be sure to perform HIV
testing in offspring of all adults living with HIV
and engaged in care.
• A second HIV test in the third trimester for
pregnant women is recommended for women at
high risk for HIV and those living in high HIV
prevalence areas. Many cases of pediatric HIV
infection could be prevented when a second HIV
test is performed in the third trimester.
• This patient had rapid emergence of
resistance to NNRTIs due to poor adherence
to treatment.
• Adherence to HAART for adolescents living
with HIV is a continuous challenge, and has to
be addressed in every clinical encounter.
• It is important to evaluate all psychological
factors involving diagnosis of HIV and AIDS in
adolescents that can influence adherence and
medical follow up.
• Sexual counseling and encouragement of
condom use become more important!
Women and Adolescents
Case Presentations
Vivian M Tamayo-Agrait, MD, FACOG, AAHIVMS
Department of Obstetrics and Gynecology
University of Puerto Rico
Faculty, Florida/Caribbean AETC
Disclosures of Financial Relationships
This speaker has no significant financial
relationships with commercial entities to
disclose.
This speaker will not discuss any off-label
use or investigational product during the
program.
This slide set has been peer-reviewed to ensure that there are no
conflicts of interest represented in the presentation.
Case #1: Pregnant perinatally infected adolescent
• This is the case of a 17 years old G1P0
adolescent with history of HIV diagnosed
at 2 y/o who comes referred from a
Pediatrics Immunology Clinic due to a
positive pregnancy test.
• Past medical history: Bronchial asthma,
lipodystrophy, major depression, suicidal
attempt
Case #1: Pregnant perinatally infected adolescent
• Past ARV experience:
– AZT and ddI (1997-1998): changed due to viremia
– Lamivudine/AZT/ritonavir: ritonavir d/c due to nausea
– Nelfinavir/AZT/3TC (1998-2000): changed due to
viremia
– Efavirenz/d4T/ddI (2000-2002)
– Lopinavir/ritonavir, 3TC/d4T (2002-2004): changed to
due viremia
– Atazanavir/tenofovir/T-20 (2004-2006): d/c due to poor
commitment with treatment
– Atazanavir/ritonavir/tenofovir/3TC: treatment at initial
visit
Case #1: Pregnant perinatally infected adolescent
• Patient brings results of three previous
resistance tests (genotypes) that showed
the following mutations:
– 2001: I84V, M46I, L90M
– 2006: no mutations detected
– 2007: no mutations detected
Case #1: Pregnant perinatally infected adolescent
• At initial visit, patient reported poor
adherence with her ARV therapy.
– Latest labs:
• CD4 count: 393 (31%)
• HIV RNA viral load: 85,826 copies/mL
• Patient was continued on current therapy and
genotype was ordered which showed the
following:
Case #1: Pregnant perinatally infected adolescent
Case #1: Pregnant perinatally infected adolescent
• Based on these results, patient was started on
Lopinavir/ritonavir, raltegravir, etravirine,
3TC/AZT
• Importance of good adherence was stressed
for both maternal and fetal reasons.
• Follow-up labs after 2 weeks on treatment
showed:
– CD4 count: 476 (31%)
– HIV RNA viral load: 5617 copies/mL
Case #1: Pregnant perinatally infected adolescent
• Labs after 2 months on new regimen showed:
– CD4 count: 530 (36%)
– HIV RNA viral load: 115 copies/mL
• The patient’s pregnancy was complicated by
delivery via emergency cesarean section at 28
weeks gestational age (WGA) due to
eclampsia.
• She delivered a baby girl, weight 3 lbs.
– The baby has been followed up at the
Pediatrics Immunology Clinic and is
confirmed negative.
Case #1: Pregnant perinatally infected adolescent
• After delivery, patient was lost to F/U for more
than a year.
– Patient had discontinued all her medications
– She had abandoned care at her
Immunology Clinic
– Had a new sexual partner
• Adherence to medications stressed in all visits
• Injectable contraception (depot
medroxyprogesterone) started
• Consistently shows poor compliance with
treatments and appointments
Case #1: Topics for discussion
• Adherence difficulties in perinatally
infected adolescents
• Managing multi-drug resistance during
pregnancy
• Contraceptive alternatives for HIV
infected women/adolescents
Case #2: Pregnancy complicated by multiple comorbidities
• This is the case of a 42 years old G4P2012
woman with history of HIV diagnosed 2 years ago
(heterosexual contact), Diabetes Mellitus type 2,
chronic hypertension referred for prenatal care
(PNC).
• Had 2 prior PNC visits with another provider, but
failed to report her serostatus to him.
• This is a desired pregnancy, since she has a new
sexual partner (who is HIV negative) who has no
children.
• Comes to the first visit in our clinic at 12 WGA.
Case #2: Pregnancy complicated by multiple comorbidities
• Current medications:
– Efavirenz/tenofovir/emtricitabine (since HIV
diagnosis) discontinued medication on her own
when she found out she was pregnant
– Metformin 500mg twice daily
– Methyldopa 250mg twice daily
• Baseline:
– CD4:368 (29%)
– HIV RNA viral load: 6376 copies/mL
– HgA1c: 8.5%, glucose=230 mg/dL
– BP= 170/95
Case #2: Pregnancy complicated by multiple comorbidities
• Patient was admitted for metabolic
control with insulin and optimization of
anti-hypertension medication.
• She was immediately started on
Lopinavir/ ritonavir and 3TC/AZT.
• Pregnancy ended at 17 WGA due to a
spontaneous abortion.
Case #2: Pregnancy complicated by multiple comorbidities
• Post expulsion follow up:
– Still desires another pregnancy
– Oriented about all the co-morbidities that
might also complicate a future pregnancy
• Advanced maternal age
• Chronic hypertension
• Diabetes type 2
– Continued on same ARV regimen,
antihypertensive medications and was
switched back to an optimized dose of
metformin
Case #2: Pregnancy complicated by multiple comorbidities
• Post expulsion follow up:
– Continues with undetectable viral load with
current regimen
– Following metabolic and blood pressure
control closely
– Recommended folic acid supplementation
– Home insemination techniques and benefits
explained to the couple
Case #2: Topics for discussion
• Importance of pre-conceptional
counseling
• Managing co-morbidities in HIV infected
pregnant women
• New recommendations about 1st
trimester use of efavirenz
• Barriers to disclosure of HIV serostatus
to HCP
• Reproductive alternatives for HIV
serodiscordant couples
#3: Preconceptional counseling for sero-discordant couples
• A serodiscordant couple (male HIV+, woman HIV-)
is referred to our clinic for counseling on
reproductive alternatives.
• Woman: 30 years old G2P1A1, without history of
any systemic illness.
• Man: 35 years old, with history of HIV diagnosed 7
years ago due to past history of IVDA. He is ARV
naïve and receiving continuous care at his local
Immunology Clinic
• No fertility problems suspected (both have
children with previous partners)
#3: Preconceptional counseling for sero-discordant couples
• Baseline evaluations (woman):
– Rapid HIV test: negative
• Baseline evaluations (male):
– CD4 count: 825 (40%)
– Viral load: 3823 copies/mL
– Hepatitis profile: negative
– Semen analysis: normal
#3: Preconceptional counseling for sero-discordant couples
• Recommendations:
– Infected partner should begin an effective ARV
treatment
– Timed intercourse and artificial insemination
techniques (ideally including sperm washing)
were discussed, including risk, benefits and
costs
– Couple referred to a Reproduction/Infertility
specialist
– PreP and PEP recommended prior and after
insemination
– Folic acid supplementation
Case #3: Topics for discussion
• Reproductive alternatives for
serodiscordant couples
• Treatment as prevention
• PreP and PEP and their role in assisted
reproduction
Adolescent Case Involving
Confidentiality and
Disclosure
Diane M. Straub, MD, MPH
Associate Professor of Pediatrics,
Chief, Division of Adolescent
Medicine
University of South Florida
Faculty, Florida/Caribbean AETC
Disclosures of Financial Relationships
This speaker has no significant financial
relationships with commercial entities to
disclose.
This speaker will not discuss any off-label
use or investigational product during the
program.
This slide set has been peer-reviewed to ensure that there are no
conflicts of interest represented in the presentation.
Case
• J is a 15 yo girl who was diagnosed with HIV
four months ago at a routine health screening
by her excellent PCP (who actually does HIV
screening).
• She had reportedly “messed up” at a party a
few months prior, had some alcohol (her first,
so she didn’t know her limit) and had sex with
an older boy at the party.
• She doesn’t remember him wearing a condom.
She says the sex was consensual and was her
only sexual activity ever. She thinks she
passed out afterwards.
Case
• Her mother does not know she is sexually active,
as “she would kill me!” Despite persistent
attempts by the PCP to get her to discuss with her
mother, she adamantly continued to refuse.
• Her excellent PCP determined that she was not at
risk to herself and tried to “hook her up” with
support services (peer mediator, referral for
linkage to HIV care), but she has not followed up,
as she is afraid of disclosure to her mother.
• She “no-showed” for an intake appointment in HIV
specialty clinic.
Case
• She now presents with acute abdominal pain,
and is accompanied by her still unaware mother.
• Examination reveals a diagnosis of pelvic
inflammatory disease (PID) and possibly a
tuboovarian abscess (TOA), needing inpatient
admission for IV antibiotics.
• She still has not had evaluation for HIV status,
nor disclosure to mother.
• Upon further questioning, she admits to
continued, reportedly consensual, sexual activity
too.
Questions
• What do you tell J after she tells you she does not want her
mother to know why she is being admitted?
• What do you tell J’s mother when she asks you about the
reason for J’s admission?
• What are the laws that protect J’s confidentiality?
• Under what circumstances could you not keep J’s diagnoses
(PID vs HIV) confidential?
• What are the potential complications for keeping J’s diagnoses
(and its implications) confidential?
• How will you work up J’s HIV?
• What about J’s contraception and barrier protection use?
• What types of medical encounters require parental consent for
treatment?
Factors to consider
• Chronological age (particularly related to
legal factors)
• Cognitive and psychosocial development
• Other health-related behaviors
• Prior family communication/parental
influence
Support for confidentiality for minors:
• Policies of professional organizations that often
support the provision of confidential health care
to minors
– Helpful to use guidelines from American Academy of
Pediatrics (AAP), Society for Adolescent Health and
Medicine (SAHM), American Medical Association
(AMA), etc. to support policies for confidential care:
post in office, handouts for parents, etc.
• Minor consent laws
– Minor consent cards outlining rights of minors to
confidential healthcare in various states
• http://www.prch.org/resources-minors-access-cards
System-level issues that may break
confidentiality inadvertently:
• Billing practices (EOB – Explanation of
Benefits)
• Appointment reminders
• Scheduling system that requires reason for
visit
• Office and other staff not knowledgeable about
minors’ rights to confidential health care
• Results follow-up
• Cannot absolutely 100% guarantee
confidentiality a priori…
Cognitive Development: Piaget’s Formal
Operational Thought
EARLY
(11-13yo)
Concrete
thought
No future
perspective
MIDDLE
(14-16yo)
Abstraction
Has future
perspective;
not always
used
LATE
(17-21yo)
Established
abstract
thought
Future
oriented
Psychosocial Development: Erikson’s
Identity Formation
EARLY
MIDDLE
(11-13)
(14-16)
Preoccupied ٨ Perspective
with body
taking
changes
Body image
LATE
(17-21)
٧ Peer
pressure
٧ Impulsivity
“Invulnerable” ٨ Autonomy
• Other health related behaviors:
– Able to manage other health concerns?
• Relationship with parent/guardian
– Concerns about disclosure based on realistic
assessment of relationship?
– Alternative adult who can provide guidance?
Parental influence:
• Early adolescence: beginning to
separate from parents and identify with
peers
• Middle adolescence: peer influences
important, may override internal sense of
right/wrong; high parental conflict during
this time
• Late adolescence: developed own
personal values that govern choices,
may accept parental values or develop
own
Parental influence:
• Adolescents see parents as “experts” on
issues of morals, values, health-related
matters, and peers as “experts” on
matters of personal taste.
• Parents can impact effectiveness of peer
influence: teens who communicate with
parents about sexual matters are less
likely to be influenced by peers on their
sexual choices.
Parental influence:
• Authoritative parenting: characterized by
limit-setting responsive to adolescent
and his/her developmental level in the
context of a warm, supportive
relationship with good communication.
Questions
• What do you tell J after she tells you she does not want her
mother to know why she is being admitted?
• What do you tell J’s mother when she asks you about the
reason for J’s admission?
• What are the laws that protect J’s confidentiality?
• Under what circumstances could you not keep J’s
diagnoses (PID vs HIV) confidential?
• What are the potential complications for keeping J’s
diagnoses (and its implications) confidential?
• How will you work up J’s HIV?
• What about J’s contraception and barrier protection use?
• What types of medical encounters require parental consent
for treatment?
Additional Resources/References
• Minor consent cards: http://www.prch.org/resourcesminors-access-cards
• Center for Adolescent Health and the Law – contains
comprehensive list of relevant publications, as well as
other resources: http://www.cahl.org/
• State Minor Consent Laws: A Summary, Second
Edition. English A, Kenney KE. Chapel Hill, NC:
Center for Adolescent Health & the Law, 2003.
(Summarizes the minor consent laws for all 50 states
and D.C.).
Additional supportive
information/resources
Ethical principles
• Autonomy – ensure patient’s own wishes,
ideas, and choices are respected and
supported
• Beneficence – provider’s responsibility to
take action to further patient’s welfare
• Nonmaleficence – minimize harm
• Justice – fair and reasonable opportunity for
access to health care similar to other
groups in society
Behavioral Theory
Azjen, Rosenstock, Bandura
Intentions not always good predictors of behavior!
• Perceived vulnerability, subjective norms
– Is she in denial? Does she even think she CAN get infected?
– She knows people with HIV and they seem healthy, it’s no big deal…
• Perceived effectiveness, ease, and desirability of
health practice
– Does she think the medicines actually work? Can she get to clinic
herself?
• Sense of self-efficacy that one can undertake the
health practice/perceived behavioral control
– Does she think she can manage her infection on her own?
Laws on minor consent
• Legal basis for minors to consent to own
care
– Helps protect confidentiality
– Some version in every state
– Assume that
• Certain minors have attained the level of
maturity or autonomy necessary to make
decisions about own health care
• Adolescents unlikely to receive some important
types of health care unless they can do so
independently from their parents
Factors to consider: legal issues
• Laws that
– define emancipation,
– determine when a minor can consent to health care,
– specify when parental consent or notification is
required/permitted,
– clarify discretion of health care professionals to disclose
information,
– provide guidance on access to health care information
and medical records
• Implications of HIPAA Privacy Rule for provision of
adolescent health services
• Limits of confidentiality
Authorization based on…
• Minor status:
– Emancipated, married, pregnant, parent, military, high
school graduate
– Living apart from parents, living independently
– Attained certain age
– Qualified as a “mature minor”
• Type of care needed:
– Contraceptive services
– Pregnancy related care
– Diagnosis and treatment of STIs/HIV
– Treatment for drug or alcohol problems
– Care for sexual assault
– Mental health services
HIPAA Privacy Rule
• Individuals’ right to access protected health
information and control disclosure of that information
• In general, if minor can legally consent/does not
require parental consent, parent does not necessarily
have the right to access minor’s health information –
determined by “state or other applicable law”
– Gives legal significance to informal agreement of
confidentiality between adolescent and provider to which
parent has given assent
– Minors who have such agreements can request specific
privacy protections
Legal limits of Confidentiality
•
•
•
•
State laws
Homicidal or suicidal ideations
Child abuse reporting laws
Reporting requirements for communicable
diseases
Cannot absolutely 100% always guarantee
confidentiality a priori…
Data support positive influence of
following parental behaviors:
• Monitoring:
–
–
–
–
Requires good communication
Communicates parental values and expectations
Requires good communication
Effects on later initiation of sex; fewer risky partners; increased
contraceptive use; less frequent intercourse, STIs, and
pregnancy
• Communication:
– Effects on later sexual initiation, fewer partners, better use of
contraception
– Adolescent perceptions of problem communication associated
with increased sexual risk behaviors
• Modeling:
– Risky parental behaviors associated with risky adolescent
behaviors
Payment issues
• Health insurance coverage: law requires
EOB (Explanation of Benefits)
– EOBs sent to policy holder/insured
– EOBs can be vaguely worded so as not to
disclose confidential information
– Medicaid does not send EOBs for
confidential services in some states
Practical issues to consider:
• Candid and complete information generally
only if provider speaks with patient alone
• Clarify confidentiality (protections and
limitations) ahead of time with both
parent(s)/guardian and patient
• Skills to encourage patient communication
with parent(s)/guardian
• Acknowledge that parental support/
communication may not be possible
Practitioner’s Role:
Respect adolescent’s evolving autonomy – set rules
for confidentiality:
• Set expectations ahead of time (pre-teen, first visit
to teen clinic), review reasons why confidentiality
important, legal statutes and practice guidelines
from professional organizations
• Encourage parental participation in care and
support of confidentiality
– Help resolve conflicts, if any
– Forced communication may be counter-productive
Practitioner’s Role:
• Establish limitations of confidentiality with
adolescent and parent a priori
– Legal limitations
– Possibility of inadvertent breach of confidentiality
• Determine competence of minor to consent:
– Sufficient autonomy and intellect to consent to or refuse
care
– Consider age and developmental maturity
– Consider gravity of illness/risks of therapy vs.
non-therapy
– Feasibility (increased incentive for youth to discuss
with parent(s)/guardian)
Practitioner’s Role:
Anticipate system-level obstacles:
• Ensure office and all staff aware of minors’
rights to confidential care, ensure practices
that support these rights
– Billing, scheduling, office staff, follow-up
• Review and try to minimize paper trail issues
in your health system
• Be aware of alternative community resources
– School-based/college health services
– Planned Parenthood/public clinics
Follow-up issues:
• Always get alternative phone numbers,
establish system for f/u a priori (eg, will
leave only message to call back, will not
call with negative/normal results, etc).
• Texting/email/etc (possible breach of
confidentiality)