1. AN UPDATE ON PAEDIATRIC HIV/AIDS AND
CHALLENGES OF MANAGEMENT IN NIGERIA
By
IMOUDU I A
MODERATOR DR UMAR L W

2. OUTLINE
 Introduction
 Epidemiology – Global, regional & National
 Pathogenesis, transmission, disease progression
 Clinical manifestations, associated conditions, Ois, clinical
staging
 Diagnosis , lab evaluation.
 HIV Testing & counselling – PITC
 Mx
 ART –ARVs , Eligibility, initiation, monitoring, adherence,
toxicities ,
 Paediatric HIV/AIDS in Nigeria – Hx, Current position,
prospects; Strategic plan;
 Challenges, strengths, & opportunities
 conclusion

3. INTRODUCTION
 HIV IS A RETROVIRUS WHICH BELONGS TO THE
FAMILY LENTIVIRIDAE
 THE VIRUS MAINLY INFECTS HELPER T
LYMPHOCYTES,MONOCYTES AND
MACROPHAGES
 AIDS RESULTS FROM PROGRESSION OF HIV
INFECTION.

4. INTRODUCTION.
 HIV WAS FIRST RECOGNIZED IN THE USA IN
1981.
ISOLATED IN 1983.
DEMONSTRATED AS THE CAUSATIVE AGENT
OF AIDS IN 1984.
A SENSITIVE ELISA TEST WAS DEVELOPED
IN 1985.

5. EPIDEMIOLOGY
 AT THE END OF 2007,WHO ESTIMATED THAT ABOUT
33.2MILLION PEOPLE WERE LIVING WITH HIV
GLOBALLY.
 16% DROP WHEN COMPARED WITH THE 2006
ESTIMATE OF 39.5MILLION.
 THE NUMBER OF PEOPLE LIVING WITH HIV IN
EASTERN EUROPE AND ASIA HAS INCREASED BY
OVER 150% FROM 630000 IN 2001 TO 1.6MIL IN 2007.
 330000 CHILDREN DIED OF AIDS GLOBALLY IN 2007.

6. Global summary of the AIDS epidemic
December 2007(WHO)
Number of people living with HIV in 2007
Total 33.2 million [30.6 – 36.1 million]
Adults 30.8 million [28.2 – 33.6 million]
Women 15.4 million [13.9 – 16.6 million]
Children under 15 years 2.5 million [2.2 – 2.6 million]
People newly infected with HIV in 2007
Total 2.5 million [1.8 – 4.1 million]
Adults 2.1 million [1.4 – 3.6 million]
Children under 15 years 420 000 [350 000 – 540 000]
AIDS deaths in 2007
Total 2.1 million [1.9 – 2.4 million]
Adults 1.7 million [1.6 – 2.1 million]
Children under 15 years 330 000 [310 000 – 380 000]

7. EPIDEMIOLOGY
• SSA STILL MOST AFFECTED ,68% ADULTS AND
90% CHILDREN LIVING WITH HIV.
• SSA ACCOUNTED FOR 76% AIDS DEATHS IN 2007.
• 1.7MILLION NEW INFECTIONS IN 2007.

8. EPIDEMIOLOGY
• NGR HAS THE HIGHEST BURDEN OF MTCT
RATES AND PEADIATRIC HIV DISEASE IN THE
WORLD.
• NGR IS ESTIMATED TO HAVE 290,000
CHILDREN LIVING WITH HIV.
• ACCOUNTS FOR 14% OF THE TOTAL AFRICAN
BURDEN.
•STATE-WIDE HIV PREVALENCE IN NGR
RANGES FROM AS LOW AS 1.6% IN EKITI TO
10% IN BENUE.

9. PATHOGENESIS

10. MODE OF TRANSMISION.
• MATERNAL TO CHILD.
• USING CONTAMINATED SKIN PIERCING
INSTRUMENTS OR SHARPS.
• INJECTION OR TRANSFUSION OF CONTAMINATED
BLOOD OR BLOOD PRODUCTS.

11. MODE OF TRANSMISION.
• UNPROTECTED SEXUAL INTERCOURSE WITH AN
INFECTED PARTNER.
• WITHOUT INTERVENTION,5-10% OF TRANSMISION
WILL OCCUR DURING PREGNANCY,10-20% DURING
LABOUR AND 5-20% DURING BREASTFEEDING.
• 15-30% OF NON-BREASTFED CHILDREN WILL BE
INFECTED OVERALL.

12. Risk Factors For Maternal To Child
Transmission
Maternal Factors
 Mothers with high viral load
 Severe immunosuppression and advanced disease
 Rupture of membranes > 4hrs before delivery.
 Cracked nipples and breast abscesses during
breastfeeding.
 Maternal micronutrient deficiencies.

13. Duration of ROM and risk
of transmission
< 4 hours > 4 hours
14% 25%

14. The effect of maternal viral load on the risk of
transmission of HIV
<1000cpm 12% Transmision
>10,000cpm 29% Transmision

15. RISK FACTORS FOR MTCT
INFANT FACTORS.
– INVASIVE INFANT PROCEDURES DURING
DELIVERY
– FIRST TWIN
– PREMATURITY
– BREASTFEEDING
– ORAL THRUSH OR ORAL ULCERS WHILE
BREASTFEEDING

16. CLINICAL MANIFESTATION.
PRIMARY ACUTE INFECTION.
• I P IS 2-4WKS FOR 10
INFECTION ACQUIRED BY
ADULTS AND ADOLESCENTS.
• NON-SPECIFIC SYMPTOMS OCCUR IN 30-90% OF
NEW INFECTIONS.
• FEVER,FATIGUE,MALAISE,PHARYNGITIS,
LYMPHADENOPATHY.

17. CLINICAL MANIFESTATION.
LATE STAGE DISEASE.
• CHARACTERIZED BY IMMUNODEFICIENCY
• RESULTING IN SUSCEPTIBILITY TO
INFECTIONS,MALIGNANCIES AND
ENCEPHALOPATHY

18. CLINICAL STAGING
IMPORTANCE
• CLARIFIES THE PROGNOSIS OF INDIV PATIENTS.
• AIDS IN DIAGNOSIS IN THE ABSENCE OF LAB
TESTING.
• AFFECTS THE TYPE OF TREATMENT INTERVENTIONS
INCLUDING INDICATIONS FOR STARTING AND/OR
CHANGING ART.

19. WHO Paediatic Staging Of HIV/AIDS Disease
Stage 1 Asymptomatic
Persistent generalized lymphadenopathy
Stage 2 -Hepatosplenomegaly
-Papular pruritic eruptions
-Seborrheic dermatitis
-Fungal nail infection
- Angular chelitis
-Lineal gingival erythema
-Extensive HPV or molluscum infection (>5% of body area/face)
-Recurrent oral ulcerations (>2 episodes/6mos)
-Parotid enlargement
-Herpes zoster (>1 episode/12 mos)
-Recurrent or chronic URTI: otitis media, otorrhea, sinusitis -(>2
episodes/ 6mos)
-unexplained moderate malnutrition not responding to standard
therapy

20. Stage 3. - Unexplained persistent diarrhoea (> 14days)
- Unexplained persistent fever (intermittent or constant, >
1mo)
- Oral candidiasis (outside neonatal period)
- Oral hairy leukoplakia
- Pulmonary TB.
- Severe recurrent bacteria pneumonia (>2 episodes/12
mos)
- Acute necrotizing ulcerative gingivitis/ periodontitis.
- LIP,lymph node TB
- Unexplained anaemia (< 8g/dl),neutropenia (<1000/mm3
)
or thrombocytopaenia (<50,000/mm3
) for > 1mo.
- Chronic HIV associated lung disease.

21. •Stage 4
•Unexplained severe wasting or severe malnutrition not
responding to standard therapy.
•Pneumocystis pneumonia
•Recurrent severe presumed bacteria infections (e.g
empyema, pyomyositis, bone or joint infections,
meningitis, but excluding pneumonia).
•Chronic herpes simplex infection: (orolabial or
cutaneous of more than 1mo duration).
•Extrapulmonary TB
•Kaposis sarcoma
•Esophageal candidiasis
•CNS toxoplasmosis (outside the neonatal period).
•HIV encephalopathy.
•CMV infection (retinitis or infection of organs other
than liver, spleen or lymph nodes: onset at age 1mo or
more)

22. •Extrapulmonary crytococcosis including meningitis.
•Any disseminated endemic mycosis (e.g extrapulm histoplas
mosis, coccidiomycosis, penicilliosis)
•Cryptococcosis
•Isosporiasis
•Disseminated non-tuberculous mycobaterial infection.
•Candidiasis of the trachea, bronchi or lungs.
•Visceral herpes simplex infection
•Acquired HIV associated rectal fistula
•Cerebral or B cell non- Hodgkin lymphoma.
•Progressive multifocal leukoencephalopathy (PML).
•HIV associated cardiomyopathy or nephropathy.

23. WHO classification of HIV-associated immunodeficiency
in infants and children
Classification of HIV-
associated
immunodeficiency
Age-related CD4+ values/percentages
≤ 11 months (%) 12-35
months (%)
36-59
months (%)
≥ 5 years (cells/µl)
Not significant >35 >30 >25 >500
Mild 30-35 25-30 20-25 350-499
Advanced 25-29 20-24 15-19 200-349
Severe <25 <20 <15 <200 or <15%
*Total Lymphocyte
Count (TLC)
<4000
cells/µl
<3000
cells/µl
<2500
cells/µl
<2000
cells/µl

24. Laboratory Diagnosis
Antibody tests.
 HIV rapid tests
 HIV enzyme-linked immunosorbent Assay
[ELISA]
 Western blot.
Antigen Detection Methods.
 HIV DNA polymerase chain reaction (PCR)
 HIV RNA PCR
 P24 antigen detection
 Viral culture.

25. INTERPRETATION OF RESULTS
 HIV infection is absent if there are at least 2
negative antigen detection tests between the
age 1mo and 6mos
 Loss of HIV antibody in a child with previously
negative antigen detection tests confirms that
the child is not infected.
 HIV infection is present if they are 2 positive
viral tests on separate blood samples
regardless of age.

26. INTERPRETATION OF RESULTS
 2 or more negative antibody tests performed
by the age of over 6mos with an interval of at
least 1mo between the tests reasonably
excludes HIV infection in exposed children.
 A positive HIV antibody test at > 18mos
followed by a positive confirmatory test
definitely indicates HIV infection.

27. COUNSELLING
• A process by which a counsellor provides adequate
information and education about a situation and
helps the client to make an informed choice of
what is best to do in that situation .
• An integral component of the approach to caring for
HIV infected/affected children, their families and
caregivers.

28. COUNSELLING
• It is a continuous process that starts from the point
of contact with the facility and continues
throughout the life of the child.

29. PITC
• HIV testing and counselling which is recommended
by health care providers to persons attending
health care facilities as a standard component of
medical care.
• The major purpose is to enable specific clinical
decisions to be made and /or specific medical
services to be offered that would not be possible
without knowledge of the child’s HIV status.

30. PITC
• PITC is voluntary and the ‘’3 Cs’’- informed CONSENT,
COUNSELLING and CONFIDENTIALITY must be
observed.
• FMOH presently recommends that PITC be offered to
all children seen in paediatric health services.

31. MANAGEMENT
 Maintenance of good nutrition
Vaccinations
 Prophylaxis and treatment of opportunistic infections
Psychological support for the family
Anti-retroviral therapy
Management of AIDS defining illnesses
Palliative care for the terminally ill.

32. ARVs
Nucleoside reverse transcriptase inhibitors (NRTIs ) Some important side effects
Zidovudine ( ZDV, AZT ) Anemia, neutropenia ,headaches ,gastrointestinal
disturbance. Lipodystrophy.
Lamivudine (3TC )
Stavudine (d4T ) Peripheral neuropathy., pancreatitis, lipodystrophy.
Abacavir (Abc )
Didanosine (ddL )
Emtricitabin (FTC )
Hypersentitivity reaction.
Non- Nucleoside Reverse trancriptase inhibitors
(NNRTIS )
Nevirapine (NVP )
Efavirenz (EFV )
Hepatitis
CNS Symptoms, increased transaminases
Nucleotide Reverse transcriptase inhibitors (NtRTI)
Tenofovir (TDF) (disoproxil fumarate) Headache, nausea, diarrhoea, bone demineralization

33. ARVs
Protease inhibitors
(PIs)
Lopinavir (LPV)
Ritonavir (RTV)
G.I intolerance ,Lipodystropy, hepatitis
Nelfinavir (NFV) Diarrhoea, lipodystrophy.
Amprenavir (APV)
Fusion inhibitors
enfuvirtide
Local injection site reaction; Hypersensitivity
reaction.

34. ARVs
 Integrase inhibitors (Raltegravir and Elvitegravir)-
currently undergoing clinical trials.
 Chemotactic cytokine Receptor (CCR5) inhibitors-
undergoing clinical trials
 Maturation inhibitors-yet to undergo clinical trials
 Use of biological agents - GBV- C
 HIV vaccine.

35. INITIATION OF ARVs
• WHO paed stage 3 or 4 irrespective of CD4+%.
• WHO paed stage 2 or 1 with CD4+ less than 25%
(1500 cells /mic) for children less than 12 months.
Less than 20% ( less than 750 cells /mic) for
children 12 – 35 months. Less than 15%(350
cells/mic) for children 36-59 months. Less than
15% (200 cells/mic) for children more than 5
years.

36. MONITORING
• This can be either clinical or laboratory.
• Required at, 1. Base line
2. During care of patients who are not yet eligible
for ART
3. Starting ART
4. Maintaining ART

37. ADHERENCE
• A partnership between the patient, family and
health care team to ensure that medication are
taking exactly as prescribed.
• Potential barriers;
 Complex medication regimens
 Difficulty in measuring or administering
medications
 Dietary requirements and restrictions

38. ADHERENCE
 Religious, cultural and personal beliefs about taking
medications
 High pill/liquid burden
 Multiple caregivers who may assume that the other
has given the medication
 Difficulty with transportation to the clinic for refills
and appointments

39. ADHERENCE
 Travel away from home or having family members
visit
 Poor palatability of ARVs
 Medication refusal
 Medication burn – out.

40. PREVENTIVE THERAPY
• PRIMARY PREVENTIVE THERAPY
• SECONDARY PREVENTIVE THERAPY
• CPT
• IPT

41. PEAD HIV/AIDS IN NGR
• NGR HAS A POPULATION OF 140MIL.
• ANNUAL GROWTH RATE OF 3.6%.
• 47% OF TOTAL POPULATION OF W.AFRICA.
• FIRST CASE DIAGNOSED IN A 13YR-OLD GIRL IN
1986.

42. PEAD HIV/AIDS IN NGR
• FMOH IDENTIFIES AIDS AS ONE OF THE IMPORTANT
CAUSES OF DEATHS IN ADULTS AGED 15-49YRS.
• FMOH PLANNED TO PROVIDE ART IN 2001.
• IMPLIMENTATION STARTED FOR ADULTS IN 2002.
• TREATMENT FOR CHILDREN DID NOT BEGIN UNTIL
2004.

43. PEAD HIV/AIDS IN NGR
STRATEGIC PLAN
• FMOH COMMITTED TO SCALING UP PEAD HIV CARE
TO ENSURE THAT AT LEAST 80% OF INFECTED AND
EXPOSED CHILDREN HAVE ACCESS TO
CARE,TREATMENT AND SUPPORT.

44. PEAD HIV/AIDS IN NIGERIA
STRATEGIC OBJECTIVES
• PROMOTE NATIONAL COORDINATION
• STRENGTHEN THE SYSTEM OF IDENTIFICATION AND
TESTING OF NEW HIV POSITIVE CHILDREN
• ENHANCE CARE FOR HIV INFECTED AND EXPOSED
CHILDREN
• EXPAND HUMAN RESOURCES

45. PEAD HIV/AIDS IN NGR
STRATEGIC OBJECTIVES
• IMPROVE COMMUNITY INTEGRATION
• IMPROVE MONITORING AND EVALUATION
• INITIATE A SURVEILLANCE PROGRAM TO ASSESS THE
NATURE OF PEAD HIV/AIDS.

46. CHALLENGES
CHALLENGES TO THE HEALTH SYSTEM
• INCREASED BURDEN ON ALREADY OVERSTRETCHED
HEALTH CARE SYSTEM
• LACK OF ACCESS TO AND POOR UPTAKE OF PMTCT
SERVICES
• INADEQUATE FACILITIES FOR EARLY INFANT DIAGNOSIS
• LIMITED HUMAN RESOURCE CAPACITY TO MANAGE PEAD
HIV/AIDS

47. CHALLENGES
CHALLENGES TO THE HEALTH SYSTEM
• ISSUES AROUND INFANT FEEDING AND COUNSELLING
• LACK OF INTEGRATION,POOR LINKAGES AND WEAK
REFERRAL SYSTEM
• WEAK LOGISTIC MANAGEMENT INFORMATION SYSTEM
LMIS
• LACK OF REGULAR MONITORING AND EVALUATION OF
SERVICES.

48. CHALLENGES
SOCIETAL
• LOSS OF PRODUCTIVE AGE GROUP
• INCREASING NUMBER OF OVC
• STIGMA,DISCRIMINATION AND CULTURAL BARRIERS
TO EFFECTIVE CARE AND TREATMENT.

49. STRENGTHS AND OPPORTUNITIES
• POLITICAL COMMITMENT BY GOVT
• WELL SPREAD HEALTH INFRASTRUCTURE
• MANY TRAINABLE HEALTH PERSONNEL AND EXPERTS
• INCREASED DEMAND FOR HIV/AIDS TREATMENT,CARE
AND SUPPORT SERVICES

50. STRENGTHS AND OPPORTUNITIES
• LOCAL PRODUCTION OF GENERIC ARVs
• INCREASING NUMBER OF IMPLEMENTING PARTNERS

51. CONCLUSION
• HIV/AIDS HAS BECOME A SIGNIFICANT CAUSE OF INFANT AND
CHILDHOOD MORTALITY AND MORBIDITY IN NIGERIA AND SERIOUS
ATTENTION BY BOTH THE GOVERNMENT AND POPULACE SHOULD
BE PAID TO ITS PREVENTION AND MANAGEMENT.
• ALL HANDS MUST BE ON DECK TO ENSURE THAT THE FMOH’S GOAL
OF PROVIDING CARE,TREATMENT AND SUPPORT TO AT LEAST 80%
OF THE CHILDREN EXPOSED TO AND INFECTED WITH HIV IS
ACHIEVED.

52. THANK
YOU

53. REFERENCES
• UNAIDS,WHO;Aids epidemic update.Dec,2007.
• Hoffman,Rockstroh,Kamps;HIV Medicine 2007.
• WHO;Guidelines on PITC 2007.
• William W Hay Jr,et al;Current pediatric Diagnosis
and Treatment 2007.
• FMOH (NGR);National Paediatric HIV/AIDS
Guidelines 2007.
• FMOH(NGR);Scale-up plan for paediatric HIV/AIDS
care,treatment and support oct,2007.
• http://en.wikipedia.org
• http://www.unaids.org