Kenya National “Comprehensive
Paediatric HIV Care Course”.
NASCOP/UON/ MU/KNH/KPA
Module 6, Adolescent HIV Care,
March 2011
1

2





Unit 1: Epidemiology of HIV in adolescents
Unit 2: Adolescent growth and development
Unit 3: Reproductive Health Services for
Adolescents
Unit 4: Comprehensive Adolescent HIV
Services
Unit 5: Life Skills and Adherence Issues
Module 6, Adolescent HIV Care,
March 2011

3
At the end of this module the learner will be able to;
1.
Describe the epidemiology of HIV in the adolescents
2.
Describe the different stages of adolescent growth and development and their potential impact on the care of the infected adolescent.
Module 6, Adolescent HIV Care,
March 2011

4
5.
6.
7.
Describe the reproductive health services for the infected adolescent.
Describe how to set-up comprehensive adolescent HIV services.
Discuss strategies for building life skills in the adolescent to support good drug adherence.
Module 6, Adolescent HIV Care,
March 2011

8.
9.
Module 6, Adolescent HIV Care,
March 2011

Kenya National “Comprehensive
Paediatric HIV Care Course”.
Module 6, Adolescent HIV Care,
March 2011
6

7

WHO defines adolescents as young people aged 10-19 years of age.

The term “Young people” refers to individuals aged 10-24 years.
Module 6, Adolescent HIV Care,
March 2011

8



The epidemic among young People is largely invisible to them & society.
Of the 15 – 24yr old people living with
HIV, 63% live in Sub-Saharan Africa.
In 20 countries 5% or more of Young
Women age 15-24 are infected.
Module 6, Adolescent HIV Care,
March 2011

In the last three years, young people have accounted for more than one third of all new infections
Source: UNAIDS, 2006, 2008, 2009
Module 6 Adolescent HIV Care,
March 2011

Sub-Saharan
Africa
(4.0 Million)
Nearly 5 million young people (15 – 24 yrs) are infected globally. Over 900,000 were newly infected in 2008, an estimated 2 500 each day
31%
♂
♀
69%
2.8 million in 10 countries
More than 1 in every 20 young people infected with HIV in 9 countries
East Asia &
♂ ♀
Pacific
(210,000)
44%
57%
Latin America & the Caribbean
(300,000)
57%
South Asia
(210,000)
43%
♂ ♀
CEE/CIS
(70,000)
♂
♀
41%
59%
52% 48%
Middle East &
♂ ♀
(89,000)
Module 6, Adolescent HIV Care,
March 2011
49%
51% ♂
♀

11

Infection rates among Young Women
(YW) are at least twice among Young
Men (YM) in most African countries.
Module 6, Adolescent HIV Care,
March 2011

Distribution of HIV infections between young males and females, aged 15 – 24 yrs in
Source: UNAIDS, Dec 2008 with additional analysis by UNICEF

13

In many African societies a girls status is only recognized when she enters into a sexual relationship and demonstrates the ability to have a baby.

Older men seek younger sexual partners. In such a relationship the girl is vulnerable because she is not able to negotiate safe sex with an older man.
Module 6, Adolescent HIV Care,
March 2011

14
Risk factors for HIV infection among young women in the general population
(Auvert 2001)




Youthful age (15-24 years)
Number of life-time sexual partners
Sex in exchange for money
 ever married*(in high HIV prevalence regions)
Married women


Older spouse# (in low HIV prevalence regions)
HIV positive spouse
Module 6, Adolescent HIV Care,
March 2011

Other risk factors for HIV infection among young women in the general population
(Auvert 2001)

Lack of male circumcision

Herpes simplex type 2 infection

Hormonal contraception

Number of years between sexual debut and marriage
15

Large age difference between partners
Module 6, Adolescent HIV Care,
March 2011

16
Proportion of men and women reporting any non-marital partners in the past 12 months in
Kisumu
(Glynn AIDS 2001;15:S51-S60)
80
% 40
30
20
70
60
50
10
0
< 20 yrs 20-24yrs men women
Module 6, Adolescent HIV Care,
March 2011
25-29yrs

17
Prevalence of STI’s among adolescents aged 15-19 years in Kisumu
Buve AIDS 2001;15:S79-S88)
40
35
30
25
20
15
10
5
0
HIV
Girls
Boys
HSV-2 CT* Syphilis
Module 6, Adolescent HIV
Care, March 2011
CT* - Chlamydia Trachomatis

18


There is an epidemic of HIV among young people in sub-Saharan Africa.
Young women are at high risk of HIV and other STDs
Module 6, Adolescent HIV Care,
March 2011

Kenya National “Comprehensive
Paediatric HIV Care Course”.
Module 6, Adolescent HIV Care,
March 2011 19

20

At the end of this unit the learner will be able to describe the different stages of adolescent growth and development and their potential impact on care of the HIV infected adolescent.
Module 6, Adolescent HIV Care,
March 2011


Adolescent development is divided into three stages;



Early adolescence
Mid-adolescence
Late adolescence
Module 6, Adolescent HIV Care,
March 2011
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22
There are three types of adolescent development:



Physical
Emotional
Cognitive
Module 6, Adolescent HIV Care,
March 2011

Early (10-
13years)
Mid (14-16 years)
Late
> 17 years
girls -breast bud, downy pubic hair near labia, peak growth velocity
Boys-darkening and enlarging scrotal sac, testicular growth, downy pubic hair
Girls- further growth of breasts, increased pigmentation of pubic hair, menarche
Boys – further increase in size of testes, enlargement of penis, growth
Mature physical development
23
Module 6, Adolescent HIV Care,
March 2011

24


Immature genital tract is more vulnerable to
STD’s and HIV

Insufficient thickness of the wall


Insufficient mucous protection
Externalization of the columnar epethelium of the endocervix to the ectocervix ( cervical ectopy)
Early maturing adolescents maybe at greater risk of peer pressure to engage in high risk behaviour.
Module 6, Adolescent HIV Care,
March 2011

Early (10-
13years)
Mid (14-16 years)
Late (> 17 years)
Wide mood swings, Intense feelings, Low impulse control
Sense of invulnerability, Risk taking behaviour peaks
Sense of responsibility for ones health,
Increasing sense of vulnerability, Able to think of others and suppress ones needs,
Less risk taking
Module 6, Adolescent HIV Care,
March 2011
25

Early (10-
13years)
Mid (14-16 years)
Late (> 17 years)
Concrete thinking
Little ability to anticipate long term consequences of their action
Literal interpretation of ideas
Able to conceptualize abstract ideas such as love, justice, truth and spirituality
Ability to understand and set limits
Understands other’s thoughts and feelings
Module 6, Adolescent HIV Care,
March 2011
26

27


Formal operational thinking where a decision making tree can be made is essential to understanding the consequences of various actions. This is achieved in late adolescence.
25% of the adult population never reach this level of thinking.
Module 6, Adolescent HIV Care,
March 2011

28
Early and mid adolescence is associated with increased risk of HIV transmission due to:




Poor impulse control
Sense of invulnerability
Risk taking behaviour
Inability to conceptualise long term consequences of actions.
Module 6, Adolescent HIV Care,
October 2007

29

Risk taking is typical of adolescents or all over the world and is characterized by;



Drug use – cigarette smoking is often the entry point into other substance abuse
Violence
Unprotected and/or casual sex
Module 6, Adolescent HIV Care,
March 2011

30
Early Adolescence
10-13years
Mid-Adolescence
14-16 years
Late adolescence
> 17 years
Increased importance and intensity of same sex relationships
Peak of peer conformity
Increased opposite sex relations
Peers decrease in importance
Begin to develop mutually supportive, mature, intimate relationships
Module 6, Adolescent HIV Care,
March 2011

31


Sexually active adolescent girls rely on their male partners for sexual decision making.
Girls will have sex to please their boyfriends even when they themselves do not enjoy it.
Module 6, Adolescent HIV Care,
March 2011

32
Early Adolescence
10-13years
Estranged
Need for privacy
Mid-Adolescence
14-16 years
Late adolescence
> 17 years
Peak of parental conflict.
Rejection of parental values
Improved communication
Acceptance of parental values
Module 6, Adolescent HIV Care,
March 2011




Adolescents have limited knowledge about
HIV/AIDS – limited access to health information and care.
Adolescents would prefer to receive information on sexuality from their parents.
Parents have many barriers to communicating about sexuality to their children including lack of information and lack of confidence in their own sexuality.
33
Module 6, Adolescent HIV Care,
March 2011

34


A persons attitudes influences the choices they make.
Adolescence with a high sense of self esteem and strong goal orientation are more likely to delay sexual activity and use contraceptives when they do have sex.
Module 6, Adolescent HIV Care,
March 2011

Summary on adolescent changes from childhood to adulthood

A period of rapid development and change:



Physical: their bodies and brains
Psychological: how they think about themselves and others; how they deal with and express their emotions
Social: their relationships and roles, expectations (of themselves and by others), opportunities, moving towards family formation, economic security, and citizenship
Module 6 Adolescent HIV
Care, March 2011



Importance of adolescent differences towards the management of HIV/AIDS in adolesence
Because these changes have implications for:


How adolescents understand and act on information
What influences them, what they are concerned about


How they think about the future and make decisions
Because adolescence is a period of:

Experimentation, risk taking and first-time experiences
A key period of sexual development: relationships, sexual debut, sexual preference …
Module 6 Adolescent HIV Care,
March 2011

37
How can families and communities ensure that adolescents grow up with a high sense of self-esteem and goal orientation?
Module 6, Adolescent HIV Care,
March 2011



Social and cultural environments are strong determinants of sexual risk taking.
Poverty and isolation may increase an adolescent’s likelihood of becoming sexually active.

Several studies on orphans in Kenya found that all girls aged 11-15 years had either had a baby, an abortion or were or pregnant (Mutemi et al.)
Module 6, Adolescent HIV Care ,
March 2011
38

39


Physical growth and development is stunted in adolescents infected with HIV in early childhood.
Slow or lack of sexual maturity, skin conditions and other diseases may lead to a low self esteem.
Module 6, Adolescent HIV Care,
March 2011

40



Guidelines for Adolescent treatment not readily available in Africa.
Adolescent guidelines are found in both adult and paediatric guidelines for treatment
(WWW.hivatis.org)
US Guidelines break down recommendations based on sexual developmental stages regardless of chronological age.
Module 6, Adolescent HIV Care,
March 2011

41


Adolescence is a unique and vulnerable time in the lives of most people.
Care for HIV positive adolescents must entail a holistic or multi-disciplinary approach that addresses physical, emotional, and social needs in addition to medical treatment.
Module 6, Adolescent HIV Care,
March 2011

42

Should HIV infected adolescents be treated like their adult counterparts or like paediatric patients or are they a unique group requiring their own treatment guidelines?



HIV disease progression and anti-retroviral drug metabolism are different in children compared to adults.
Adolescents may be regarded as falling into a gray area somewhere in between the two.
Differences in pathogenesis and response to treatment have not been extensively studied
Module 6, Adolescent HIV Care,
March 2011

43



Dosages for HIV and anti OI medications follow paediatric schedules for persons in early adolescence (10-13yrs old);
Adult schedules should be followed in Mid to Late adolescent stages (≥14yrs old).
Close monitoring for those in Midadolescent stage to ensure that there is no overdosing on the treatment.
Module 6, Adolescent HIV Care ,
March 2011

44

Support an adolescent with HIV to
“graduate” into adult services when s/he
“ages out” of youth-specific programmes to ensure a smooth transition.
Module 6, Adolescent HIV Care,
March 2011

45



Generally pathogenesis and response to treatment among adolescents are similar to adults
ARV treatment is characterized by growth spurt as well as sexual and cognitive maturation.
Potential for good immune reconstitution following ART due to presence of thymic tissue
Module 6, Adolescent HIV Care,
March 2011

46


Adolescence is a stage of rapid physical growth, and mental development.
Sexual maturation is completed well before emotional and cognitive development.
Module 6, Adolescent HIV Care,
March 2011

47


Adolescents are physically and sexually mature enough to engage in what is perceived as “adult” activities e.g. smoking, taking alcohol, sex etc.
The lack of cognitive maturation and experience makes it difficult for the adolescent to perceive today’s actions are directly related to tomorrow’s consequence.
Module 6, Adolescent HIV Care,
March 2011

48



Coping with a life-threatening illness during adolescence , a tumultuous and difficult period in life can be overwhelming.
HIV disease management is complicated for many teenagers and their providers, in addition to issues of poverty, STD co – infection, school stress, physical and substance abuse.
Adolescents with HIV should have the right to expect high-quality medical care tailored to their needs so that they make the transition to healthy adulthood.
Module 6, Adolescent HIV Care,
March 2011

Kenya National “Comprehensive
Paediatric HIV Care Course”.
Module 6, Adolescent HIV Care,
March 2011 49

50

At the end of this unit the learner will be able to describe the reproductive health services for the HIV infected and affected adolescent.
Module 6, Adolescent HIV Care,
March 2011

51






A 16 year old female presented at the adolescent Clinic at
Machakos District Hospital (MDH) brought by an aunt
In private consultation revealed




Has been sexually active; partner (older man) does not know status but have broken up now
She has a vaginal discharge
H/o two previous abortions
Not using any contraceptives
STI treatment and condoms provided, counseled on use and referred to FP clinic
She went to the FP clinic, but did not receive services – she was asked to wait, but did not want to.
In the interim, she got another boyfriend.
A few weeks later, she came back with a history of a third abortion, and reported that the condom ‘burst’
Module 6, Adolescent HIV Care,
March 2011

52



List the reproductive health services that are required by adolescents.
Module 6, Adolescent HIV Care,
March 2011

53






Provide young people with correct information
Active promotion and support for abstinence
Prevent STDs and HIV in sexually active adolescents e.g correct use of condoms
Treatment of sexually transmitted diseases
Access to contraceptives.
Development of life-skills e.g avoidance intergenerational sex; have single HIV negative partner
Module 6, Adolescent HIV Care,
March 2011


Promote healthy sexual development
54

Provide information and skills to the adolescents so that they can protect themselves from negative consequences of sexuality.
Module 6, Adolescent HIV Care,
March 2011

55




Be comfortable with their own sexuality
Be well informed on adolescent development and related health care needs.
Be familiar with community norms on sexuality.
Create an atmosphere that encourages adolescents to consult


Initiate discussion on sexuality
Have sex education materials in the waiting room

Have separate consultation time for adolescents
Module 6, Adolescent HIV Care,
March 2011

56



Educate parents on how to discuss sexuality with their children guide them to make appropriate choices.
Provide health messages to adolescents that are appropriate for the developmental stage.
Approach sexuality in anticipatory manner right from the first paediatric visit – use correct terminologies to describe body parts.
Use culturally acceptable language.
Module 6, Adolescent HIV Care,
March 2011

57

History taking – should cover


Family
School



Peer group characteristics
Sexual history
Risk taking behviour (smoking,violence)
(Use self-administered questionnaires to collect sensitive information)
Module 6, Adolescent HIV Care,
March 2011

58


The adolescent should be given a complete physical examination that includes a vaginal examination for sexually active adolescent girls.

Most girls are too shy to complain of STD related symptoms.
Treatment of STI’s should follow the syndromic approach.

If resources are available wet preparations for bacterial vaginosis, and trichomoniasis, and cultures for gonorrhoea should be done
Module 6, Adolescent HIV Care,
March 2011

59





Address myths about STI’s and HIV
Identify types of sexual encounters
Provide accurate information on
 sexual feelings,



 sexual physiology, sexual relations,
STI’s and family planning
Provide individual counseling
Offer VCT to sexually active adolescents
Module 6, Adolescent HIV Care,
March 2011

60

It is important to meet the adolescent at their point of need.
Module 6, Adolescent HIV Care,
March 2011

61
Key messages are;

Sex should never be forced on any one

It is better to delay child bearing beyond adolescence


It is possible and practical to abstain from sexual activity
It is acceptable to abstain from sexual activity.
Module 6, Adolescent HIV Care,
March 2011


Includes married and single youths. Educate on:

Contraception: methods and access.


Prevention and treatment of sexually transmitted diseases.
Provide counseling to the couple

HIV infected adolescents need to know that they can infect a sexual partner or their unborn child.

Secondary abstinence
Module 6, Adolescent HIV Care,
March 2011
62


All methods of family planning can be used safely in HIV infected adolescents.

Sexually active adolescents should be encouraged to use dual methods – a condom plus an effective contraceptive method.
Module 6, Adolescent HIV Care,
March 2011
63


These are effective and safe

Hormonal contraceptives increase genital shedding of HIV and therefore puts the partner at higher risk of HIV.

Hormonal contraception increases the female’s vulnerability to bacterial and viral STD’s including
HIV.

64
Thus dual contraception recommended
Module 6, Adolescent HIV Care,
March 2011

Causes of Hormonal Contraception failure.

Anti-microbial agents used in treatment of infections (Rifampicin, Erythromycin) and
Anticonvulsants (barbiturates, carbamazepine), reduce efficacy of hormonal contraception by increasing the rate of liver metabolism.

Diarrhoea and vomiting interferes with absorption of oral contraceptives.
65
Module 6, Adolescent HIV Care,
March 2011

66


Information on where to access contraception counseling, STI services and PMTCT should be widely available to the adolescents.
Services should be provided at a cost that is affordable to the adolescent.
Module 6, Adolescent HIV Care,
March 2011

67



Adolescents require a comprehensive package of reproductive Health services
Services need to be tailored to the needs of both sexually active and inactive adolescents.
Sexually active adolescents need to use dual contraception
Module 6, Adolescent HIV Care,
March 2011

Kenya National “Comprehensive
Paediatric HIV Care Course”.
Module 6, Adolescent HIV Care,
March 2011 68


At the end of this module the learner will learn how to set-up comprehensive adolescent HIV services
69
Module 6, Adolescent HIV Care,
March 2011

70
Module 6, Adolescent HIV Care,
March 2011

71

Concerns of the HIV infected adolescent.

Health


Peer relationships
Sexuality

School and community


Academic and social performance
Stigma

Secrecy
Module 6, Adolescent HIV Care ,
March 2011




This should be done in a caring supportive atmosphere
An authoritarian manner should be avoided.
A good assessment of the adolescent’s living situation should be made.
Module 6, Adolescent HIV Care,
March 2011



The SHADASS assessment is a quick and effective tool for gaining insight into the adolescent’s world.
It provides a framework for discussions of all areas of the adolescent’s life.
Source: Rudy,B,J.Textbook of Pediatric HIV Care2005
Module 6, Adolescent HIV Care,
March 2011








S=School
H=Home
A=Activities
D=Depression/Self-esteem
S= Substance abuse
S=Sexuality
S=Safety
Source: Rudy,B,J.Textbook of Pediatric HIV Care2005
Module 6, Adolescent HIV Care,
March 2011



Origin of referral


Health institutions – Hospitals, health centres, VCTs, etc
Community – Schools, Orphanages, CBOs, Support groups, Self, etc
Challenges of testing

Lack of adolescent friendly services



Ability to conceptualize issues and to give consent
Naivety and peer influence
Stigmatisation
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March 2011
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76
Approach to Adolescent Testing




Use of peer educators, counselors and support groups
Provide adolescent friendly clinics
Empower health workers to communicate with adolescents
Sensitize and educate parents and teachers in handling adolescent issues.
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March 2011

77




Should be done by the parent/caregiver and/or the health worker

Parents/caregivers lack the skills, therefore are reluctant to do this
Benefits the adolescent to accept their status and live positively
Reduces risk of HIV transmission
Improves adherence to care and treatment
Module 6, Adolescent HIV Care ,
March 2011

78
Module 6, Adolescent HIV Care ,
March 2011



Infected adolescents

Long term survivors of MTCT of HIV.

Youths infected during childhood or adolescence as a result of high risk behaviour
At risk of infection

Adolescents engaging in high risk behaviour

Youth in long-term sexual relationships

Orphaned adolescents
Module 6, Adolescent HIV Care ,
March 2011
79

The needs of adolescents with HIV depending on the transmission period
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March 2011

81




Lack of information
Most HIV infected adolescents are unaware of their status because they have not tested.
There is a lack of policy to guide HIV testing services for adolescents.
Most VCT clinics are not comfortable offering
HIV testing to adolescents.
Module 6, Adolescent HIV Care ,
March 2011

Although there has been improvement in comprehensive correct knowledge among young people, STILL only 30 per cent of young men and 19 per cent of young women have accurate and comprehensive knowledge of HIV.
Most countries are far from reaching the UNGASS 2010 targets
Developing countries with 10 or more percentage point increase in the percentage of young women and men aged 15-24 with comprehensive correct knowledge of HIV Source: UNICEF global databases, 2010 (MICS, DHS and other national surveys, 2003-2008)
Young women aged 15-24 Young men aged 15-24
Global 2010 target (95%)
Namibia 2000-06/07
Trinidad and Tobago 2000-06
Rwanda 2000-05
Guyana 2000-06
Cambodia 2000-05
23
31
33
36
37
54
51
50
50
65
Namibia 2000-06/07
Rwanda 2000-05
Viet Nam 2000-06
Sao Tome and Principe 2000-06
Moldova 2000-08*
Suriname 2000-06
11
19
25
27
Dominican Republic 1999-2007
Gambia 2000-06
Tanzania 199907/08‡
Haiti 2000-05/06
Cameroon 2000-06
Uzbekistan 2000-05
Armenia 2000-05
Central African Republic 2000-06
Jordan 2002-07
0
18
15
26
15
16
3
7
5
3 13
17
23
34
32
31
10 20 30
41
39
39
44
44
42
41
Tanzania 1999-
07/08‡
Haiti 2000-05/06
India 2001-05/06
Benin 2001-06
Nigeria 2003-08
Indonesia 2002/03-2007*
40 50 60 70 80 90 100
Module 6 Adolescent HIV Care,
March 2011
0
14
0
15
17
20
21
20
29
28
33
36
35
41
42
40
40
54
Global 2010 target (95%)
62
60 80 100





Denial of HIV infection – delay in care entry sometimes as a coping mechanism or due to other stresses

Difficulties with complex care associated with HIV.

Module 6, Adolescent HIV Care ,
March 2011
83



Access to HIV Testing &
Counselling
Care and psychosocial support, including for those not yet requiring treatment

Access to service providers who are sensitive to adolescents' needs

Disclosure of HIV status
(both to adolescents and
Module 6, Adolescent HIV Care,
March 2011 to those who can support them)




Adherence to treatment
Continuum of care i.e. transition from paediatric to adult care
Dealing with stigma & discrimination

Preventing behaviours which put them and partners at risk of HIV infection

Support to consider their future reproductive
Module 6, Adolescent HIV Care,
March 2011 health

86

Plan comprehensive services for adolescents that includes pre-ARV and ARV care for HIV infected adolescents for (1) Private doctor clinic (2) District hospital setting (3) health center setting.


Where and when will the services be provided, by whom?



What will be the non-clinical eligibility criteria?
How do you cater for the disenfranchised youths?
How do you avoid stigma?
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March 2011

87
Youth-Friendly HIV Services for adolescents: Rift
Valley Provincial & General Hospital- Nakuru


Dedicated time and space for adolescent consultation and services
In addition to HIV services, provide




Pregnancy screening
Mental health consultations by psychiatrist
Condom counseling and provision
Nutritional counseling
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88
Youth-Friendly HIV Services for adolescents: :
Rift Valley Provincial & General Hospital- Nakuru



Counseling
Adolescent support group
As of Mar 2011:



16 patients seen each clinic day
30 HIV+ youths attend an adolescent support group
32 caregivers attend a caregivers’ support group.
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89
Youth-Friendly HIV Services for adolescents: : should follow these processes

On specific days: girls and boys separately; given a topic to write about e.g. experiences with stigma in the home, school, community

Providers review and discuss responses

Next support group day, adolescents discuss solutions and identify what help these youth friendly
HIV services can provide towards solving these problems.
Module 6, Adolescent HIV Care ,
March 2011

Youth-Friendly HIV Services for adoloscents :
Rift Valley Provincial & General Hospital- Nakuru
90

Adolescents difficulties , such as drug abuse, intimate or sexual relationships, pregnancy and behaviour changes counseling and testing, should be communicated and discussed with
 caregivers via caregivers’ support group
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March 2011

91
Youth-Friendly HIV Services for adoloscents :
Rift Valley Provincial & General Hospital- Nakuru

Schools staff should be sensitized; with caregiver and adolescents’ consent, school nurses should be invited to support group meetings

Adolescents can express themselves through drama and song
Module 6, Adolescent HIV Care ,
March 2011

92
Module 6, Adolescent HIV Care ,
March 2011

93
Selection of which ARV drugs must consider:

Sexual developmental stage



Paediatric regimens & doses for no or early adolescent development stage adult ART regimens and doses for mid and late adolescent development stages
Sexually active female (risk of pregnancy)

In first line regimen use nevirapine as third drug.
Avoid efavirenz due to potential teratogenicity
Module 6, Adolescent HIV Care ,
March 2011

Age Clinical Stage CD4% CD4 count
< 18 months ALL ALL ALL
18 months – 5 years
5-12 years
>12 years
WHO 3 or 4
WHO 3 or 4
WHO 3 or 4
< 25%
< 20%
< 1000
< 500
<350
Child fulfilling any of the above criteria requires ART.
*Child < 18months with presumptive stage 4 HIV diagnosis, preferable to have
CD4 evidence of immuno-suppression before ART initiation
94
Module 6, Adolescent HIV Care ,
March 2011


Preparation (medical and counseling):




Clinical evaluation & treatment for TB, STI, other
OI
Treat TB (may delay ART if CD4 > 350mm 3 )
Disclosure of HIV status to adolescent
Assessment of social situation
Module 6, Adolescent HIV Care,
March 2011
95

1 st Line for Children & Adolescent
(NASCOP 2010)
96
Age < 3 years or <
10kg
Age > 3 years and over
10kg
Abacavir (ABC)
+
Lamivudine (3TC)
+
Nevirapine (NVP) or Boosted
Lopinavir(Lp/r)
In ABC hypersensitivity replace it with AZT
Abacavir (ABC)
+
Lamivudine (3TC)
+
Efavirenz (EFZ) or (NVP) or
Lp/r
In ABC hypersensitivity
Module 6, Adolescent HIV
Care, March 2011 replace it with AZT

Kenya National Recommended
2 ND Line ART in children/ Adolescent
First line

ABC /3TC/NVP or
EFV
Second line

AZT /3TC/LPV/r
97

AZT /3TC/NVP or
EFV

TDF* /3TC/LPV/r
Module 6, Adolescent HIV Care,
March 2011
*in children over
13yrs

NVP exposure less than 2 years ago)
First line

ABC + 3TC + LPV/r

AZT + 3TC + LPV/r
Second line

AZT+3TC+new boosted PI

TDF*+3TC+New boosted PI
*only if over 13yrs
98
Module 6, Adolescent HIV Care ,
March 2011

Treatment failure in children & adolescents in early adolescence
CHILDREN &
ADOLESCENTS
IN early adolescent development stage
Clinical

New or recurrence of
WHO Stage 3 or
4 disease

Lack of or decline in growth response over a
6-month period, after treating for excluding other causes, e.g. malnutrition, TB
Immunologic

Return in CD4 cell percentage or count to pretherapy baseline or below threshold levels for age

> 50% fall from peak level on
ART of CD4 cell percentage or absolute count
Virologic

Persistently elevated VL despite effective
ART

Progressive increase in VL after starting effective ART

Repeated VL detection in children with earlier undetectable levels

Treatment failure in children adolescents in early adolescent development stage
CHILDREN
& adolescent
s in early adolescent development stage
Clinical
 o Failure to meet neurodevelopmental milestones
Immunologic

New progressive age related severe immunodeficiency

Development of severe
Immunodeficiency after initial immune recovery

Rapid rate of decline to below threshold of age related severe immunodeficiency

Severe Immunodeficiency
(CD4 < 15%)
Module 6 Adolescent HIV Care,
March 2011

Clinical
ADULTS &
ADOLESCENTS in mid to late adolescent development stages

After 6 months of effective ART
 indicate TF2:

Recurrence of prior opportunistic conditions
Onset of new
WHO Stage 3
& 4 conditions
Immunologic Virologic

Fall of > 50% of
CD4 from peak value

Return of CD4 to ≤ pre- ARV treatment level

Failure to reduce
VL to undetectable levels after 24 weeks of effective ART

A sustained increase in VL after a period of full suppression
Module 6 Adolescent HIV Care,
March 2011

Kenya National “Comprehensive
Paediatric HIV Care Course”.
Module 6, Adolescent HIV
Care,March 2011 102

103

These are skills that help the adolescent to adjust and operate appropriately within society.

Self help skills


Social skills
Cognitive skills
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March 2011

104

When the adult is away, how does the adolescent operate?
Discuss
Module 6, Adolescent HIV Care,
March 2011

105





Personal Hygiene
Personal Grooming
Culinary skills (how well can you cook?)
Domestic Chores
Adherence to care and treatment
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March 2011

106

Question: When a visitor comes home, how do you respond?
Discuss
Module 6, Adolescent HIV Care,
March 2011

107

Social skills: help harmonious interaction with other people





Greetings
Apology
Receptive and helpful
Assertive skills
Anger Management

How do we manage our anger?
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March 2011

108

Am I intelligent?
Discuss
Module 6, Adolescent HIV Care,
March 2011

109

Cognitive skills: help one to appraise a situation and make appropriate decisions

One’s intelligence in academics


Ability to think and act in an appropriate manner in challenging situations
Conflict resolution and Problem solving
Module 6, Adolescent HIV Care,
March 2011


The acquisition of these life skills essential for building and sustenance of the adolescent’s self esteem
110
Module 6, Adolescent HIV Care,
March 2011

111

There are two groups of HIV infected adolescents who require treatment and therefore adherence counseling:


Adolescents who have been in long term care and now need to become more directly involved in their own care.
Newly diagnosed adolescents
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March 2011

112





Knowledge of their disease and available treatment.
Adequate social support and stability
Acceptance of sero-status and need to start treatment
Access to supportive health care providers
Meets clinical and/or laboratory criteria for initiation
Module 6, Adolescent HIV Care,
March 2011









Does not qualify by clinical or laboratory criteria for treatment
Unstable living conditions
Lack of social support
Drug abuse
Fatalistic attitude towards death,
Other mental health issues
Lack of readiness
Simple refusal
Module 6, Adolescent HIV Care,
March 2011
113

114




Physical, Psychological, Social, Cultural and Economic attributes of adolescence:
Economically dependent,
Socially inexperienced,
Less access to health care
Module 6, Adolescent HIV Care,
March 2011



Mental health issues

Depression


Depressed individuals lack the motivation to carry on with life’s activities
Encourage adolescents to discuss their problems with care providers. Psychiatric treatment may be required.

Drug abuse

Substance abuse interferes with ART adherence.

Alcohol use increases the risk of ARV drug toxicity.
Social environment
Module 6, Adolescent HIV Care,
March 2011
115

Module 6, Adolescent HIV Care,
March 2011
116

117

Strategies To Enhance ARV Drug
Adherence Among Adolescents
Good counseling and preparation to create a
positive approach to treatment that nurtures the adolescent’s belief in their success

Use of simple regimens – a once or twice daily regimens likely to work best

Adolescents are more likely to discontinue a regimen on their own if they encounter any difficulties. Regimens should fit into the adolescents life as much as possible.
Module 6, Adolescent HIV Care,
March 2011

Counseling & strategies to Enhance ARV
Drug Adherence Among Adolescents
118

Give information proactively, in appropriate language and in writing as adolescents may not ask questions on their own.

Use real life examples to illustrate, as adolescents often think in concrete terms

Educate on expectations while on therapy and how to manage side effects and adherence problems.
Module 6, Adolescent HIV Care,
March 2011


Counseling & strategies to Enhance ARV
Drug Adherence Among Adolescents(3)
Practice drug adherence with vitamin pills and septrin prophylaxis before starting ARV.

Explore challenges experienced in taking drugs & work out strategies to address them.

Educate on the need to continue taking drugs even when they are feeling well or unwell.

Develop a good relationship with the adolescent so that they see you as their partners in health.
119
Module 6, Adolescent HIV Care,
March 2011

120
Help The Adolescent Develop An
Individual strategy for drug adherence (1)





Establish a routine for taking drugs
Keep the drugs where they can see them in the morning and evening.
Take the ARV drugs at the same time every morning/evening.
Write notes and stickers to remind them to take the drugs.
Keep a diary of how they are taking their drugs and to review it with the care provider.
Module 6, Adolescent HIV Care,
October 2007

Help The Adolescent Develop An
Individual Strategy For Drug Adherence (2)
121

Plan ahead how to take ART when they are away from home.

Plan for sudden events that change the normal routine - always have a few tablets with them.

Identify a treatment partner – has been successful in adults. Adolescents who are living alone may find it difficult to find a treatment partner.
Module 6, Adolescent HIV Care,
March 2011





Life skills training makes adolescents knowledgeable, confident, and able to take responsibility for their lives.
Provide information regarding their bodies and how they will grow.
Discuss how HIV may slow growth and expected changes with ARV.
Help them develop positive strategies for coping with stigma.
Module 6, Adolescent HIV Care,
March 2011
122

123



Help adolescents develop skills in building
friendships and networks. These will be the source of sustenance when family members die.
Spiritual development helps the adolescent build resilience to cope with difficult major life events.
Education and vocation training will help provide the adolescent with skills to earn a livelihood.
Module 6, Adolescent HIV Care,
March 2011

124

There is a good evidence base for interventions to prevent HIV among young people, including behavioural, biological and societal interventions

Groups of young people who require special attention include adolescent girls, most-at-risk adolescents and adolescents living with HIV
Module 6 Adolescent Care, March
2011

125

Young people remain at the centre of the HIV pandemic

Despite important progress, national HIV/AIDS programmes have not given sufficient attention to young people and in general we are far from achieving the 2010 UNGASS goals
Module 6 Adolescent Care, March
2011

126
Module 6, Adolescent HIV Care,
March 2011

127
Challenges to providing reproductive health services to adolescents (1)





Physical, Psychological, Social, cultural and Economic attributes of adolescence:
Economically dependent, socially inexperienced, learning about protection from infection, less access to health care
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March 2011

128
Challenges to providing reproductive health services to adolescents (2)




Social Emotional and psychological development incomplete,
Experimenting with risky behavior including alcohol, and drug use
Delinquency, and challenging authority
Limited knowledge about HIV/AIDS – limited access to health information and care
Module 6, Adolescent HIV Care,
March 2011

Challenges to providing reproductive health services to adolescents (3)
Poverty and Deprivation
 Young people esp. Young women at particular risk – sex trade, sugar daddies for gifts, school fees, etc.
 Civil unrest, internally displaced people, refugees
Discrimination and Social intolerance of YP
–
Policies towards youth reflect adult views on what young people should and should not be doing not what they really need e.g need for medical Confidentiality: informing Parents about test results without the consent of YP
129
Module 6, Adolescent HIV Care,
March 2011

Stage
Other changes
I
(0-15yrs)
Breast growth Pubic hair growth
Pre-adolescent none Preadolescent
II
(10-15yrs)
Breast bud
(areolar hyperplasia
Long downy pubic hair appears with with small amount of breast buds or later breast tissue)
October 2007
Peak velocity growth soon after stage II
130

Stage
Breast growth Pubic hair growth
Other changes
III
(10-17yrs)
Further enlargement of breast tissue and areolar with no separation of the contours
Increased amount and pigmentation of the hair
Menarche in
25% of the girls in late stage III
Module 6, Adolescent HIV Care,
March 2011
131

132
Stage
IV
(10-17yrs)
V
(121/2-
18yrs)
Breast growth Pubic hair growth
Separation of contour, areolar and nipple form secondary mound above breast tissue
Adult type but not in distribution
Large breast with single
Adult distribution contour
October 2007
Other changes
Menarche occurs in most girls in stage IV 1-3 yrs after thelarche
Menarche occurs in
10% of girls

Stage
Testes Penis Pubic hair Other changes
I
(0-15yrs
Preadolescent <
2.5cm
Preadolescent none
133
II
(10-15yrs
Testes enlarges
Minimal or no growth in
Long downy hair
Pigmentation size appears of scrotal sac after testicular
Module 6, Adolescent HIV Care,
October 2007 growth
Preadolescent

Stage
Testes Penis Pubic hair Other changes
134
III
(0-15yrs
IV
(10-15yrs
Further enlargement
Further enlargement especially in width
Increased amount and curling
Further enlargement
Further enlargement especially in width
Module 6, Adolescent HIV Care,
October 2007
Adult type but not in distribution
Axillary hair and some facial hair develops

135
Stage
IV
(13-18yrs
Testes Penis Pubic hair Other changes
Adult size Adult size Adult type and distribution
(medial aspects of the thighs and line alba
Module 6, Adolescent HIV Care,
October 2007
Body continues to grow and muscles to increase in size for several monthsyear

136



Sexually transmitted diseases in adolescents present in the same way as in adults.
Globally there is an epidemic of STD’s among adolescents.
Local research has shown that the high prevalence of genital herpes among young women is a risk factor for HIV infection.
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March 2011

137


It is believed that adolescents who are infected through sexual behaviors or needle sharing experience a course of disease similar to those of adults
(NIH, 1998)
Less known about the disease course in those who were infected perinatally. Longterm observational studies of perinatally infected children will provide data on HIVpositive children as they mature into adolescence.
NIH funded Women and Infants Transmission study
(WITS)
Module 6, Adolescent HIV Care,
March 2011