1. 1 Management, Care for infants who were born from infected mothers HAIVN Harvard Medical School AIDS Initiatives in Vietnam

2. 2 By the end of this session, participants should be able to: Describe the process of management and care for exposed/infected children Define OI prophylaxis, immunization and needed lab tests for exposed and infected children Learning Objectives

3. 3 Overview

4. 4 Most children born from HIV-infected mothers are carrying maternal antibodies Maternal antibodies will be gradually eliminated in the first 18 months Children are confirmed HIV infection if still having HIV antibodies after first 18 months Diagnosis of HIV infection in infants >18 months: ELISA <18 months: PCR Diagnosis of HIV infection

5. 5 Management of children at OPC can help: Reduce the mortality HIV-infected children have the mortality up to 50% in the first 18 months of their life These children should be developed and grew as other normal children. Importance of management and care for children born fromHIV-infected mothers Note: differentiate between infected and exposed infants

6. 6 Management of exposed children

7. Receiving childrenClinical and Laboratory assessmentCounseling and SupportManagement Make plan of monitoring and other necessary supports Management of exposed children

8. 8 Making medical outpatient chart for HIV exposed infants Writing the child's name in the logbook for monitoring HIV-exposed infants Receiving children

9. 9 Clinical assessment at the first time when register and every follow-up visit: General condition, clinical symptoms Physical, mental, and cognitive development Immunization Current medications, side effects (if any) OI diagnosis and treament (if any) Clinical and laboratory assessment (1)

10. 10 Lab test: Indicate as soon as possible appropriate test to confirm HIV status accordingly to their age group. PCR: 4-6 weeks ELISA: ≥ 18 months Clinical and laboratory assessment (2)

11. 11 Determine who are the main and supportive care givers for the infants Family and care givers should be counseled on: Doing HIV confirmative testing for infants. Immunization and OI prophylaxis for infants Risk of HIV infection through breast feeding Psychological and social support Introduce HIV care and treatment service Supportive solutions for orphaned and abandoned infants Counseling and support

12. 12 Provide OI prophylaxis with Cotrimoxazole Provide treatment for OIs, symptoms, and other conditions (if any) Admit to hospital with severe cases Seek for consultation from or refer patients to relevant facilities if beyond treatment capacity Management

13. 13 Confirmative diagnosis by testing as soon as possible Schedule follow-up visit For infants missing visit, find out the reasons and establish supportive solutions. Schedule visits whenever abnormallities occur. Dispense drugs as prescribed. Coordinate the supports from family and community with available services. Follow-up plan and other neccessary supports

14. 14 Management of infected children

15. 15 Small Group Discussion Things should be done at the OPC in order to manage well HIV-infected children

16. 16 Receiving childrenClinical and Laboratory assessmentCounseling and SupportManagement Make plan of monitoring and other necessary supports Management of infected children

17. 17 Making medical outpatient chart for HIV infected infants Writing the child's name in the logbook for monitoring HIV-infected infants Provide out-patient card for infants (if any) Receiving children

18. 18 Clinical assessment at the first time when register and every follow-up visit: General condition, symptoms, clinical and immunological stages Physical, mental, and cognitive development Immunization Current medications, side effects (if any) OI diagnosis and treament, screening of TB and other conditions. Clinical and laboratory assessment (1)

19. 19 Lab tests: Complete blood count, Total lymphocyte count, ALT: At the first visit Every 3-6 months CD4: Every 3-6 months or Infants with severe progress Other necessary tests Clinical and laboratory assessment (2)

20. 20 Similar to exposed children, and add more issues on: The progress of HIV infection, importance of long-term care and treatment The need of: Clinical monitoring Doing lab tests to assess the progress of HIV infection Counseling should be focused on: Disclosure of HIV status of infants to family’s members Preventive measures of HIV transmission Safe behaviors practice Counseling and support

21. 21 Provide OI prophylaxis with Cotrimoxazole Provide treatment for OIs, symptoms, and other conditions (if any) Assess criteria of ARV treatment: Not eligible : making long-term plan to follow Eligible: preparing readiness for ARV treatment Already on ARV: Perform the process of follow-up visit Re-assess, consult to choose proper regimen if infants referred from other places. Management (1)

22. 22 Admit to hospital with cases: Complicated OIs Severe side effects Seek for consultation from or refer patients to higher level if beyond treatment capacity Coordination with specialized facilities (TB, dermatology & venerology, etc.) Management (2)

23. 23 Making specific schedule of follow-up visits for every infant: 1-2 months/time For infants missing visit, find out the reasons and establish supportive solutions. Schedule visits whenever abnormallities occur. Dispense drugs as prescribed. Coordinate the supports from family and community with available services. Follow-up plan and other neccessary supports

24. 24 Immunization

25. 25 Brainstorming

26. 26 Widely used across the country : BCG Hepatitis B Diphtheria - Pertusis - Tetanus (3-vaccine combination) Poliomyelitis (orally) Measles Encephalitis due to H. influenzea type b (5-vaccine combination) Japanese encephalitis Optional vaccine: Encephalitis due to H. influenza type b (single or combined vaccine) Varicella, mumps, rubella… Vaccinations

27. Vaccines under the National Expanded Program on Immunization VaccineExposed infants Infected children, clinical stages 1,2, 3 Infected children, clinical stage 4 BCGas scheduledDo not give Diphtheria- Pertussis- tetanus as scheduled Poliomyelitisas scheduled Only use injectable vaccine Hepatis Bas scheduled Measlesas scheduled Do not give 5-vaccine combination as scheduled Japanese encephalitis as scheduled

28. 28 Optional Vaccine Vaccine Exposed infants Infected children, clinical stages 1,2, 3 Infected children, clinical stage 4 Hibas scheduled Varicellaas scheduled Do not give Mumpsas scheduled Do not give Rubellaas scheduled Do not give

29. 29 All HIV-exposed children should receive BCG. Postpone vaccination until HIV infection is excluded in following situations: High risk of HIV infection: mother and infant not receiving PMTCT Signs or symptoms suggestive of HIV infection Having symptoms or conditions of clinical stage IV Low birth weight < 2500g,or was born pre- term After vaccination, it could have swollen lymphonode, enlarged liver and spleen, and cachexia. Consultation with TB specialists. Một số lưu ý khi tiêm chủng

30. 30 HIV infected children have mortality rates up to 50% in the first 18 months of life For HIV exposed/infected infants/children need to comply with the process of care management : Receive Clinical and laboratory assessment Management Supportive counseling and monitoring Need to counsel for care givers on the importance of immunization and monitoring closely its schedule Key Points

31. 31 Thank you! Questions?

32. 32