1. Pediatric HIV/AIDS: Orphans & Vulnerable Children

2. How comfortable are you treating children? How many of you work in a clinic that treats children?

3. Orphans Children under 18 years who have lost either a mother, a father, or both parents due to HIV/AIDS As of 2007, 1.2 million AIDS orphans in S.A.; 416,000 of these in KwaZulu- Natal

4. Vulnerable Children All children are vulnerable Contributing factors: –HIV/AIDS infection –TB infection –Loss and grief –Children headed households –Poverty –Violence in home

5. P.M.T.C.T Prevention of mother to child transmission of HIV Nurses advocate for testing and P.M.T.C.T. treatment Why might nurse or expectant mother be reluctant to discuss P.M.T.C.T.?

6. Testing of Infants & Children Test exposed infants at 6 weeks (PCR=“viral load”) PCR testing is done until 12 months old– if child is greater than 12 months, 2 rapid antibody tests are performed

7. Pediatric Lab Results Antibody test not diagnostic until 18 months Use CD4% (not absolute CD4 T-cell count) from birth to 5 years – 35% –12 - 35 months: > 30% –36 - 50 months: > 25%

8. Pediatric ARV Clinical Criteria Criteria –> 2 HIV-related hospitalizations in past year or one prolonged hospitalization (> 4 weeks) –Child satisfies W.H.O. stage III or IV –CD4 < 20% if < 18 months CD4 18 months

9. Pediatric ARV Psychosocial Criteria Mandatory: –At least one recommended caregiver who is able to administer ARVs or supervise administration Recommended: –Disclosure to another adult living in same house (who can assist with the child’s ARVs)

10. Pediatric PCP Prophylaxis Criteria Begin prophylaxis at 6 weeks of age if: –Mother is HIV-positive –Mother’s status is unknown, but child has features of symptomatic HIV Begin prophylaxis age > 18 months if: –Child is HIV-positive and not receiving ARV therapy –Child is on ARV therapy, but CD4 remains < 15%

11. Pediatric Tuberculosis Children < 5 years are at highest risk HIV infection increases risk May be difficult to diagnose: –Child may not be able to recognize and describe symptoms –Inadequate sputum specimens

12. Pediatric Tuberculosis Treatment As with adults, TB treatment takes priority over ARVs If ARVs have already been started, regimen may need adjusting If possible TB treatment should be completed prior to starting ARVs unless child is ill and: –CD4 < 5% (start ARVs after at least 2 weeks of TB treatment) –CD4 = 5 - 10% (start ARVs after 2 months)

13. Pediatric Assessment Tools Accurate weight with every visit –Weight and height necessary for body surface area calculation Children are not just small adults –Immature verbal skills-- body language very important (“look and listen”)

14. Pediatric Procedures Preparation is key Parent/caregiver involvement in exam and procedures is essential Tips to decrease pain & fear: –Allowing infant to suck something sweet during needle sticks decreases pain –Distraction techniques for children –Allow child to have control as possible –Use minimal restraint necessary**

15. Special Considerations Nurse may feel uncomfortable with pediatric care –Acknowledge personal fears/discomfort –Seek out experienced colleague if available Common procedures –Venipuncture –Vaccine & other medication administration

16. Pediatric Nurse Advocacy Discussing consent for testing with parent(s) –Testing of infant/child has implications for parent(s) Discussing consent for testing with guardian –Family member (grandmother) Prior loss & grieving Connecting traditional & Western medicine –Non-family foster parent

17. Pediatric HIV Testing Legislation South African Children’s Act –Child age 12 or older may consent alone if “sufficiently mature to understand the implications of the test” –If child is abandoned by parent/guardian for > 3 months, caregiver may consent –Consent by parent/guardian “cannot be withheld unreasonably” Nursing implications?

18. Thank You!!