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Advanced Teaching Topics The following topics are important to be familiar with but may be best taught by more experienced providers living and working in their respective countries in sub-­ Saharan Africa. 34. HIV Sources: WHO, Pocket book of hospital care for children, 2013; Eddleston et al, Oxford handbook of tropical medicine, 2008; World Bank, HIV epidemic in Tanzania mainland, 2008. Botswana National Guidelines: /Handbook_HIV_treatment_guidelines.pdf Malawi National Guidelines: /tx_malawi_2014.pdf Tanzanian National Guidelines: /tanzania_art.pdf MALAWI—HIV prevalence ranges from 10% to 15%, depending on location. Rates are higher in women, in urban settings, and along border regions. 34. HIV 131 TANZANIA—HIV prevalence among women presenting to antenatal clinics ranges from 10% to 20%, depending on location. Higher rates are noted along trading routes and in border towns and the lake zone. Epidemiology • Untreated children:ºº 25–30% will be rapid progressors—typically die before first birthdayºº 50–60% will be average progressors—develop symptoms early in life, with slow downhill course; typically death occurs by 3–5 y.o.ºº 5–25% will be long-­term progressors—live beyond 8 y.o.; typically have lymphoid interstitial pneumonitis, stunting, low weight for age, low height for age • Mother-­to-­child transmission: In utero exposure, delivery (highest risk), breastfeeding; risk of transmission ~20–45%. Prevention of Mother-­ to-­ Child Transmission • Single-­dose nevirapine:ºº 200mg nevirapine PO to mother during laborºº 2mg/kg to infant within 72 hours of delivery • Dual therapy:ºº Mother: AZT from 28 weeks gestation + 200mg nevirapine PO once during laborºº Infant: AZT for 1 week after delivery + 2mg/kg nevirapine PO once within 72 hours of delivery • Triple-­ drug antiretroviral therapy (ART):ºº ART in second trimester in all women indicated Signs/Symptoms Suggesting HIV • Recurrent bacterial infections (≥3 in 12 months) • Oral thrush 132 Advanced Teaching Topics • Chronic parotitis • Generalized lymphadenopathy • Unexplained hepatomegaly • Persistent and/or recurrent fevers ≥7 days • Progressive neurologic impairment • Microcephaly • Developmental delay • Hypertonia • Mental confusion • Herpes zoster • HIV dermatitis (erythematous papular rash) • Chronic suppurative lung disease • Chronic otitis media (≥14 days) • Chronic diarrhea (≥14 days) • Moderate or severe acute malnutrition • Esophageal candidiasis • Pneumocystis jiroveci (aka carinii) pneumonia (PJP) • Lymphocytic interstitial PNA • Kaposi sarcoma • Acquired rectovaginal fistula Diagnosis • History, physical exam, PITC • Testing indicated for:ºº All infants and children in HIV-­ epidemic regions (prevalence >1% in pregnant women).ºº All HIV-­ exposed infants at birth or earliest opportunityºº All infants and children with signs/symptoms suggestive of possible HIVºº All pregnant women and partners in HIV-­ epidemic regions HIV Staging For children 5% of body area)ºº Recurrent oral ulcerations (≥2 episodes in 6 months)ºº Recurrent or chronic upper respiratory tract infections (≥2 episodes in 6 months) • Stage 3:ºº Unexplained moderate malnutritionºº Unexplained persistent diarrhea (>14 days)ºº Unexplained persistent fevers (>1 month, intermittent or constant)ºº Oral candidiasis (outside neonatal period)ºº Oral hairy leukoplakiaºº Pulmonary TBºº Severe recurrent presumed bacterial PNA (≥2 episodes in 6 months)ºº Acute necrotizing ulcerative gingivitis or periodontitisºº Lymphoid interstitial PNAºº Unexplained anemia (1 monthºº HIV-­related cardiomyopathyºº HIV-­related nephropathy • Stage 4:ºº Unexplained severe wasting or severe malnutrition (no response to standard treatment)ºº Pneumocystis jiroveci pneumonia (PJP)ºº Recurrent severe presumed bacterial infections (eg empyema, pyomyositis, bone or joint infection, meningitis, excludes PNA) (≥2 episodes in 1 year) 134 Advanced Teaching Topicsºº Disseminated or extrapulmonary TBºº Disseminated mycobacterial disease other than TBºº Chronic orolabial or cutaneous herpes simplex infection (lasts >1 month)ºº Kaposi sarcomaºº Esophageal candidiasisºº Symptomatic HIV seropositive infant 1 month)ºº Candida of trachea, bronchi, or lungsºº Acquired HIV-­ related rectovesical fistulaºº Cerebral or B-­ cell non-­ Hodgkin lymphomaºº Progressive multifocal leukoencephalopathyºº HIV encephalopathy Treatment • Follow national guidelines and referral to HIV specialists for continued long-­ term care • Antiretroviral therapy drug classes:ºº Nucleoside reverse transcriptase inhibitors (NRTIs) * Zidovudine (ZDV, AZT) * Lamivudine (3TC) * Abacavir (ABC) * Emtricitabine (FTC) * Tenofovir (TDF)ºº Nonnucleoside reverse transcriptase inhibitors (NNRTIs) * Nevirapine (NVP) * Efavirenz (EFV) 35. Malaria 135ºº Protease inhibitors (PIs) * Lopinavir/ritonavir (LPV/RTV, aka LPV/r) * Atazanavir (ATZ)ºº Triple therapy is standard of care—typically based on 2 NRTIs + 1 NNRTI or PI • Co-­ trimoxazole prophylactic therapyºº For prevention of PJP, also common bacterial infections, toxoplasmosis, malariaºº Indications: * All infected children * All infants born to HIV-­ infected mothers until proven HIV-­ negative and no longer at risk of acquiring HIV infectionºº Doses: approximately 6–8mg/kg trimethoprim PO daily * Children 5 y.o., 1 adult tablet (80mg trimethoprim + 400mg sulfamethoxazole)ºº Dapsone is best alternative if allergic to co-­ trimoxazole 35. Malaria Sources...


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