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HIV infection & HIV testing:moon: (HIV Laboratory for Diagnostic …
HIV infection
&
HIV testing
:moon:
HIV Laboratory for Diagnostic
:white_flower:
Consent/Assent (Document & Verbal)
Pre test counseling (Group counseling is Ok)
Post test counseling (Individual counseling)
Window period (4 weeks)
Same day counseling, HIV testing & result
3 HIV testing with different Ag
(rapid tests are acceptable)
If inconclusive result ➯ repeat at
2 wks
and/or
1 mo
later
if
still
inconclusive after 1 mo ➯ report as Negative
If 1st
positive
result (newly Dx) ➯ repeat HIV testing is rec (prevent human error)
Counseling
:silhouettes:
Client-initiated testing & counseling (CITC) - ผป ต้องการตรวจเอง
Provider-initiated testing & counseling (PITC) - ผู้ให้บริการ แนะนำให้ตรวจ (ผู้ป่วยปฏิเสธการตรวจ)
Telling Blood result
in
private
➯ shouldn’t tell via telephone or other media
Keeping secret
- not telling unrelevant ppl except needed to do following law
:mountain:
Laws for HIV testing
Ppl who are below 18 years old whom request HIV testing ➯ No need to ask for parents’ permission if requester understand infection & definition of blood checking
If requester still depends on parents ➯ consider telling test result to parents if telling em are more beneficial tho we should tell requester about this too
อารมณ์บอกเด็กไปว่า บอกผู้ใหญ่เถอะเพราะการดูแล ต้องการความช่วยเหลือแก่ผู้ใหญ่
HIV testing
:game_die:
HIV ‘antibody’ testing
:three:
Enzyme-linked immunosorbent assay: ELISA
Agglutination assay
Immunochromatography
Dot immunoassay
Combination of Ag/Ab testing
:game_die:
HIV ‘viral’ testing
:two:. Nucleic acid amplification testing (
NAT
):
qualitative assay (positive/negative)
RNA in plasma
Pro viral DNA in infected cells (age < 24 months)
➯ so children < 2 y/o testing won’t found HIV infection
:one:.
p24 antigen
HIV serological assays
1st gen
2nd gen
3rd gen
4th gen
UNAIDS & WHO rec using
3 screening tests
PMTCT:
Prevention of mom to child HIV transmission
:eight_spoked_asterisk:
:pear:
Risks
evaluation for adequate prophylactic regimen
:sunny:
High
risk
Newborn who
Momใกล้คลอด
มี
VL > 50 copies/mL
or
If
no VL
result but Mom ได้
ยา HAART ไม่สม่ำเสมอ < 12 wks ก่อนคลอด
มีประวัติ
กินนมแม่หลังคลอด
:partly_sunny:
Standard
risk
Newborn who
Momใกล้คลอด
มี
VL ≤ 50 copies/mL
or
If
no VL
result but Mom ได้
ยา HAART สม่ำเสมอ ≥ 12 wks ก่อนคลอด
:pear:
The needs & pros for
Dx of HIV asap
To evaluate efficacy of preventing transmission of organism fr mom ➯ child
To F/U rate of HIV infection fr mom to child
To following prevention & Rx in OI (opportunistic infection) that may happens in child
To considering gives & stopping Anti-HIV in infected and non infected child
NO
:frowning:
Breastfeeding ➯ Drink นมผสม
:pear:
PCP Prophylaxis
Starts
at 4-6 wks of age until evidence of no infection
Doses
: Co-trimoxazole (TMP-SMX) 150 mg/m2 of TMP/day x 3 days/wk
:pear:
Evaluation for Risk of TB contact
&TB prophylaxis if indicated
:pear:
HIV DNA PCR
for Dx HIV infection
for ทารกแรกเกิด :baby::skin-tone-2:
:sunny:
High risk
: test
age
Birth
1 mo.
2 mo.
4 mo.
:partly_sunny:
Standard risk
: test
≥ 2 Times
age
1 mo.
2-4 mo.
If :heavy_plus_sign: check 2nd time immediately
Age
≥ 25 days
can check
HIV DNA PCR at 1 mo.
Baby who born fr HIV infected mom should check
anti-HIV
@
18 mo.
to confirm Dx
If HIV DNA PCR :heavy_plus_sign: for the
1st time
ทำไรบ้าง
➯
Repeat
HIV DNA PCR + HIV RNA, viral resistance
➯
Starts
Anti-HIV: AZT + 3TC + LPV/r ระหว่างรอผล repeated HIV DNA PCR
➯ Look at
HIV DNA PCR
result
If :heavy_plus_sign:
for 2 times
➯ HIV infection that
need to eat anti-HIV for the rest of the life
If repeated HIV DNA PCR is :heavy_minus_sign: — not asso. with 1st result ➯ Consult specialist/Refer
:pear:
Rx
according to risks
:sunny:
High
risk
ให้ 3 Anti-HIV drugs(AZT+3TC+NVP) continuously
until reaching 6 wks
or
until blood result
@ 1 mo. come back
:orange_book::
:orange_book:
Result are :heavy_minus_sign: ➯
stops
3 drugs
Result aere :heavy_plus_sign: ➯
repeat test
and change fr NVP to
LPV/r
:partly_sunny:
Standard
risk
ให้เด็กกิน
AZT for 4 weeks
to prevent mom to baby transmission
:glass_of_milk:
Formula
1st formula
in children :grapes:
Never receiving
anti-HIV drugs
before :grapes:
:warning:
Evaluation before starting anti-HIV drugs
Purpose: To
screen for co-infection
&
Rx opportunistic infections
( :arrow_down: risk of immune reconstitution inflammatory syndrome)
TB
➯ CXR
Hepatitis B
➯ HBsAg
(if HBsAg :heavy_plus_sign: ➯ Tenofovir + Lamivudine or Emtricitabine)
Hepatitis C
➯ anti-HCV
(In high risk: IVDU, NB with maternal IVDU, or Maternal HCV infection)
CMV retinitis
➯ Eye exam by Ophthalmologist
< 5 yr old with CD4 ≤ 5% or 50 cells/mm3
≥ 6 yr old with visual defect or floater
STD screening for teenage
➯ Hx taking & Physical exam + VDRL
:glass_of_milk:
PCP prophylaxis
I/C
:check:
:<3:1. Baby born fr HIV infected mom (assume that mayb HIV infection)
Should
Start
Anti-viral prophylaxis since age
4-6 wk
Stop
prophylactic drug when prove that mom is not HIV infected
:<3:2. Unknown status/Uncertain diagnosis of Baby born fr HIV infected mom
Should be given drugs
until age 12 mo.
:<3: 3. HIV pt that age > 1 yr
CD4 ≤ 15% or CD4 ≤ 500 cells/mm3 in child 1-5 yr old
CD4 < 200 cells/mm3 in child ≥ 6 yr old
rapidly :arrow_down: CD4 or in clinical CDC category C
:green_heart:4. Used to be PCP before
:<3::
Primary prophylaxis
:green_heart::
Secondary prophylaxis
Dosage
:pill:
:pill:
TMP
5 mg/kg or 150 mg/m2/day
with
SMX
750 mg/m2/day OD or bid for
3 days/wk
(Max: TMP < 320 mg & SMX < 1,600 mg)
If Allergic to TMP/SM in child age ≥ 1 mo. ➯
Dapsone 2 mg/kg
OD (max < 100 mg)
or
4mg/kg once per wk (max < 200 mg)
If Allergic to Dapsone ➯
Atovaquone
Note:
low CD4 should
start anti-HIV before 2 wks
to prevent Opportunistic infection
:arrow_down: misunderstanding of SEs caused by OI or Anti-HIV
to test adherence
:no_entry:
Stops Primary or Secondary PCP prophylaxis
when?
(ครบ 2 ข้อ)
Receive anti-HIV drugs for
≥ 6 mo.
CD4 ≥ เกณฑ์
for
≥ 3 mo
.
Child 1-5 yr old: CD4 > 15% or > 500 cells/mm3
Child ≥ 6 yr old: CD4 ≥ 15% or ≥ 200 cells/mm3
Child < 1 yr old
needs prophylactic drugs until 1 yr regardless of CD4 number
:syringe:
Immunization in HIV infected child
:candy:
HIV infected child ที่อายุถึงเกณฑ์ที่ต้องรับ vaccine
CD4 > 25% ➯ can
start vaccine immediately
regardless whether receiving anti-HIV drugs or not
CD4 < 15% & starting anti-HIV drugs ➯
wait ≥ 6 mo. after receiving anti-HIV drugs & CD4 > 15% then ➯ give vaccine
:candy:
Post-exposure prophylaxis
Eg. Tetanus or Rabies
as Receiving vaccine won’t build good immunity in HIV-infected child regardless of full vaccine program
Consider
Immunoglobulin (Ig)
that specific after expose to disease
including บาดทะยัก (TIG) และ พิษสุนัขบ้า (RIG)
:candy:
BCG vaccine
for
every
newborn whose delivered from HIV-infected mom
:!: If never receive BCG at birth & HIV infection already proven ➯
shouldn't gives vaccine
:candy:
MMR vaccine
given if
CD4 > 15%
(gives like normal child)
:!:
not given
in Low immunity (
Clinical stage C or CD4 < 15%)
:candy:
JE vaccine
--
Inactivated
3 times
1mo.
(ห่างกัน 0 mo, 1 mo, 1 yr) & should stimulate อีก 1 ครั้ง after 3rd time for ≥ 4-5 yr
:warning:
shouldn't inject Activated vaccine
:candy:
Influenza vaccine
(HIV child - risk group) should get vaccine in child ≥ 6 mo.
:candy:
Other vaccines
are given like normal child
:tada: should get vaccine
Hib, IPD, HPV
:pill: เกณฑ์ on Anti-HIV Drugs in Children & Teenager in Thailand
➯ Recommend to
start Rx ทุกราย
โดย
กรณี
ต่อไปนี้ควร
เริ่มยา asap
< 1 yr
starts Rx
ทุกราย
อย่าง
เร่งด่วน
as of High death rate in 1 yr
1 to < 5 yr
Got presenting
symptoms
in WHO stage 3,4
or
CD4 lvl ต่ำกว่าเกณฑ์
(1-3 yr: %CD4 < 25 or จำนวน CD4 < 1,000 cells/mm3)
(3-<5yr: %CD4 < 25 or จำนวน CD4 < 750 cells/mm3)
≥ 5 to 15 yr
Got presenting
symptoms
in WHO stage 3,4
or
CD4 < 500 cells/mm3
For
every teenager
, should start Rx
asap
to prevent transmission to others
If not ready to start drugs & no symptoms & CD4 higher than said criteria
➯ may consider
F/U
symptoms & CD4
for at least q 6 months
WHO Clinical Stage
:koala:
:koala:
Stage 1
No symptoms
LN โตทั่วตัว
:koala:
Stage 2
เริ่มมีโรค
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions (PPE) (ผื่นผิวหนังอักเสบ)
Angular cheilitis (มุมปากอักเสบ)
Linear gingival erythema (เหงือกอักเสบ)
แผลในปากเป็นๆหายๆ
Extensive wart virus infection (หูด)
Extensive molluscum contagiosum (หูดข้าวสุก)
Fungal infection at nails
Unexplained persistent parotid enlargement
Herpes zoster (งูสวัด)
Recurrent or Chronic Upper respiratory infections
eg. Otitis media, Sinusitis or Tonsilitis
:koala:
Stage 3
full blown HIV
Skinny thin, Moderate malnutrition in which not response to Rx
Unknown cause of chronic diarrhea for ≥ 14 days
Unknown cause of chronic fever for ≥ 1 month
Persistent oral candidiasis after age 6-8 weeks
Oral hairy leukoplakia (ฝ้าขาวที่ลิ้น)
Acute necrotizing ulcerative gingivitis or Periodontitis (เหงือกอักเสบเป็นแผลหรือเยื่อหุ้มฟันอักเสบ)
TB LN
Pulmonary TB
Chronic lung infection - lymphoid interstitial pneumonitis style
Severe bacterial pulmonary infection
Chronic lung ds from HIV infection including Bronchiectasis
Pale without known cause
Hb < 8 g/dL or
Neutrophil < 500 cells/microL or
Chronic low pltsp (< 50,000 cells/microL)
:koala:
Stage 4
full of opportunistic infections
Pneumonia fr PCP (Pneumocystis jiroverci)
Skinny thin, Moderate malnutrition in which not response to Rx
Got severe bacterial infection for many times
eg. empyema, pyomyositis, bone&joint infection
not include pneumonia
Herpes simplex
infection for > 1 month
Extra
pulmonary TB
Non-tuberculous mycobacterial infection (Disseminated Type)
Candida
infection in esophagus, trachea, or lungs
Toxoplasmosis
infection in brain (after age 1 month)
CMV retinitis or CMV infection in other organs (after age 1 month)
Cryptococcosis
infection outside lung including meningitis
Disseminated endemic mycosis
eg. Histoplasmosis, Coccidiomycosis, Penicillosis
Chronic
diarrhea from
Cryptosporidium
or
Isospora
สมองฝ่อ from
HIV encephalopathy
สมองเสื่อม from Progressive multifocal leukoencephalopathy
Myocardial dysfunction from
HIV-asso. cardiomyopathy
Abnormal kidney from
HIV-asso. Nephropathy
CA
Kaposi’s sarcoma
Lymphoma Z
in brain (B-cell non-Hodgkin lymphoma)