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Tips for working with children with HIV

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Tips for working with children with HIV Dr Beauty Osei-Sekyere Introduction HIV/AIDS major cause of infant and childhood morbidity and mortality in Africa In ... – PowerPoint PPT presentation

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Title: Tips for working with children with HIV


1
Tips for working with children with HIV
  • Dr Beauty Osei-Sekyere

2
Introduction
  • HIV/AIDS major cause of infant and childhood
    morbidity and mortality in Africa
  • In children under 5 years of age, HIV/AIDS now
    accounts for 7.7 mortality worldwide
  • AIDS already accounts for gt 19 in infant
    mortality and 36 rise in under - 5 mortality
  • Together with factors such as declining
    immunization, HIV/AIDS is threatening recent
    gains in infant and child survival and health
  • Ref Handbook on Paediatric AIDS in Africa, 2006
    pg 11

3
  • Yet, HIV infection in children is preventable
  • In developed countries, paediatric HIV infection
    has largely been controlled
  • In these settings, HIV testing as part of routine
    ANC, combinations of ARV drug regimens, elective
    C/S and complete avoidance of BF have translated
    into MTCT rates of lt 2

4
  • In Africa, on the other hand ?rates of maternal
    HIV infection, ? birth rates, lack of access to
    currently available and feasible interventions,
    and widespread practice of prolonged BF lead to ?
    burden of paediatric HIV disease

5
  • African setting - transmission risk for a child
    born to HIV mother (without interventions for
    PMTCT) 30 40
  • The other 60 - 70 of children, although HIV
    negative , still have 2-5 fold risk of mortality
    as a direct consequence of moms HIV disease,
    c.f. children born to HIV - moms

6
  • Efforts to expand care and Rx for children must
    go hand in hand with efforts to rapidly improve
    uptake of available interventions for ? MTCT
    (these reach 10 of population in countries
    most affected)
  • Access to currently available, effective care and
    Rx remains a major obstacle

7
  • The fast rate of HIV progression and ?
    morbidity/mortality among infants and children
    with perinatally acquired HIV infection means
    that identifying these children and enrolling
    them in care programmes should be considered an
    emergency

8
Guiding Principles
  • As signatories of the UN Convention of the Rights
    of the Child, health care providers must comply
    with the following 4 principles
  • Right to life, survival and development
  • Right to equitable treatment and care
  • Right to participate in activities and decisions
    that affect them
  • All actions should be based on the best interests
    of the child

9
  • In managing HIV-positive children and their
    caregivers, apply the following principles
  • Do not discriminate
  • Be compassionate and show empathy
  • Maintain confidentiality at all times
  • Establish and maintain clear 2-way communication
    between all levels of the health car system
    (clinics and hospitals) regarding Mx of the child

10
  • 5. Involve all health-care personnel and
    parents/caregivers in important patient care
    decisions
  • 6. Pay attention to pain and suffering, and
    preserve quality of life for long as possible

11
Principles of Medical Management
  • HIV still not curable, but can now be managed as
    a chronic condition
  • There are interventions that can significantly
    improve the childs quality of life survival
    time
  • Most care support can be provided _at_ Iº care
    level
  • Where referral is indicated, provide caregiver
    with clear explanation of illness, referral
    letter and a follow-up plan

12
Modes of HIV Transmission to Children
  • Mother-to-child transmission (MTCT) accounts for
    most HIV- infected children
  • Sexual abuse particularly in countries with high
    level of child abuse, e.g. SA
  • Blood transfusion rare as long as transfused
    blood is carefully screened. There is risk where
    blood donor was in window period
  • Insufficiently sterilised instruments,
    traditional scarification
  • Wet-nursing with HIV-contaminated breast milk

13
Risk factors for MTCT
Maternal factors Infant factors
High viral load Prematuritry
Low CD4 count Breastfeeding
Advanced AIDS Oral problems
Low Vitamin A level Invasive foetal monitoring during labour
Prolonged rupture of membranes (PROM)
Cracked nipples or other breast condition
14
  • HIV re-infection may be one of the factors
    responsible for ? VL during perinatal period or
    subsequently
  • Maternal vitamin A supplementation does not
    decrease MTCT and may increase risk of breast
    milk transmission

15
Prognostic factors
  • Without intervention most children infected at
    birth will develop features of disease by 6 mo.
  • As disease progresses, OIs become apparent with
    a downward course much more rapid than in adults
  • This rapid progression largely determined by
    immature immune system
  • Additional factor ? maternal VL at birth

16
Prognostic factors cont...
  • Progression is divided into 3 categories
  • Category 1 Rapid progressors die within the
    first year( 25-30 )
  • Category 2 Features of infection appear early in
    life and disease progresses more slowly with
    death occurring within 3-5 years (50 - 60 )
  • Category 3 Long term survivors who live beyond
    8 years of age (5 - 25 )

17
Prognostic factors cont...
  • Other factors affecting prognosis
  • In-utero infection
  • Signs of infection before 4 mo. of age
  • Maternal ?VL and ?CD4 count _at_ time of delivery
  • Rapid downhill course of mom
  • Maternal death

18
Prevention of primary infection
  • Reduce heterosexual transmission. Ensure that men
    are involved
  • Prevent infection during pregnancy and lactation
  • Keep adolescent girls and boys in schools with
    appropriate health/sexuality education
  • Comprehensive Mx of STIs
  • Prevention of unintended pregnancies among
    HIV-infected women

19
Diagnosis of HIV Infection in Children
  • HIV ELISA test detects HIV
  • antibodies in the blood
  • Mothers transmit antibodies to baby through the
    placenta therefore
  • HIV ELISA test ve lt18 months ?HIV infection
  • HIV ELISA test ve gt18 months HIV infection

20
Diagnosis of HIV Infection in Infants
  • Polymerase chain reaction (PCR) detects the viral
    genetic material
  • PCR advisably from 6 weeks post natal.
  • If baby is breast-feeding, PCR to be repeated
  • 6 weeks after cessation of breast feeding
  • Much more sensitive and specific than ELISA.

21
Recommendations for diagnosing HIV in Infants
  • PCR at 6 weeks of age and/or 6 weeks
  • post Breast Feeding
  • PCR ve result and symptomatic consider infected
    and manage as such (NB all children who failed
    PMTCT are at high risk of death and should be
    strongly considered for early ART initiation)
  • PCR ve (and not breastfeeding, HIV-uninfected
    and should be followed up as for HIV negative
    children.
  • PCR ve and asymptomatic, monitor monthly as per
    guidelines
  • Continue Cotrimoxazole for all positive children
    and stop if PCR ve.

22
Opportunities for reaching children in need of
HIV care
  • Constant vigilance is essential. Pro-active steps
    to detect these children include
  • PMTCT records should identify all HIV- exposed
    children
  • Children with severe pneumonia, severe
    malnutrition, chronic/persistent diarrhoea and TB
    must be tested for HIV-infection
  • Siblings should be tested
  • Special risk orphans and vulnerable children
    (OVC)

23
  • CLINICAL FEATURES OF HIV- INFECTION

24
Clinical signs/conditions suggestive of
HIV-infection in children
  • Common in HIV children but uncommon in
    uninfected
  • Severe bacterial infections, esp. if recurrent
  • Persistent or recurrent oral thrush
  • Bilateral painless parotid swelling
  • PGL other than inguinal
  • Persistent or recurrent fever
  • Neurological dysfunction
  • Herpes zoster- single dermatome
  • Persistent dermatitis not responding to Rx

25
Signs and conditions common in both HIV and HIV
children
  • 1. Chronic ear infection
  • 2. Persistent / recurrent diarrhoea
  • 3. Severe pneumonia
  • 4. Tuberculosis
  • 5. Bronchiectasis
  • 6. FTT
  • 7. Marasmus

26
Signs and conditions very specific to
HIV-infection
  • Pneumocystis jiroveci pneumonia (PCP)
  • Oesophageal candidiasis
  • Extrapulmonary cryptococcosis
  • Invasive salmonella infection
  • Lymphoid interstitial pneumonitis (LIP)
  • Herpes zoster affecting several dermatomes
  • Kaposis sarcoma
  • Lymphoma (not necessarily)
  • Rectovaginal or rectovesical fistula

27
CARING FOR HIV EXPOSED CHILDREN
  • HIV exposure
  • - occurs during pregnancy, birth and
    breastfeeding.
  • - without intervention MTCT occurs in 30-40 of
    infants
  • NB Risk of dying even for HIV-uninfected
    children of mothers who have died of AIDS is
    increased 3-4 times (need for vigilance and
    accurate counseling of caregivers at every visit)

28
What should be done at clinic visits?
  • Counseling of the mother
  • 1. Potential common HIV related issues (in mom
    or infant)
  • 2. Cotrimoxazole implementation to be stressed
    (6-week visit)
  • 3. Clear follow up schedule to be negotiated

29
  • Growth monitoring
  • FTT important indicator of HIV-infection or
    failure to respond to ART (FTT WHO stage 3
    criterion, and stage 4 if severe)
  • Weight should be recorded on the RTHC and the
    curve interpreted
  • If FTT noted, intensify assessment for
    HIV-related features (try to identify treatable
    causes)
  • Introduce food supplementation (after excluding
    and treating infections)

30
Caring for the HIV-exposed cont...
  • Dietary advice
  • Immunisation
  • Routine oral Vitamin A supplementation
  • Routine de-worming
  • Co-trimoxazole prophylaxis
  • Counselling and social support

31
CARING FOR THE HIV-POSITIVE
  • Health care for HIV children includes the
    following
  • Confirmation of HIV status
  • Staging of disease
  • Rx of all infections, incl OIs
  • Regular monitoring of growth and development
  • Nutrition support schedule
  • Completion of immunization
  • Co-trimoxazole prophylaxis
  • Counselling of mom/caregiver
  • Consideration for ART

32
Cotrimoxazole (Bactrim) Prophylaxis
  • Bactrim prevents the following conditions
  • - PJP (PCP), invasive bacterial disease,
    nontyphoidal salmonella, toxoplasmosis,
    streptococcus pneumoniae
  • When should it be started?
  • AT 6 wks in an infant born to HIV mom
  • At any time when the infant/child fulfils the
    initiation criteria

33
Bactrim prophylaxis cont...
  • Who should receive it?
  • Any infant born to HIV mom irrespective of
    whether the woman received ART during pregnancy
    or labour
  • Any infant who is identified as being HIV
    infected during 1st yr of life (PCR)
  • Children gt 12 months c pre Hx of PCP, or more
    than 2 episodes of any pneumonia, or have
    symptomatic HIV or AIDS defining illness

34
Bactrim prophylaxis cont...
  • When can it stopped?
  • for children lt 1yr of age, prophylaxis should
    continue until HIV infection has been excluded
    and risk of exposure has ceased, e.g. breast
    feeding stopped
  • Ref Gauteng Health Department

35
  • When should it be continued?
  • Prophylaxis should be continued for life if HIV
    child has
  • Had an episode of PCP(PJP)
  • Had 3 or more pneumonia episodes
  • Symptomatic HIV disease or an AIDS-defining
    illness

36
Co-trimoxazole prophylaxis approx. doses
Weight Approx. age Co - trimoxazole daily dose
6 wks to 2 months lt 5 kg 2.5 ml
2 to 12 months 5 9.9 kg 5 ml
12 to 24 months 10 14.9 kg 7.5 ml
2 to 60 months4 15 - 21.9 kg 10 ml or 1 tablet
gt 60 months gt 22 kg 15 ml or 11/2 tablets
37
  • NB Co-trimoxazole allergy - Dapsone is a good
    alternative
  • Dosage 1mg/kg daily to a maximum of 100 mg

38
Pre HAART Mx
Counselling support
  • Immunization

Dentists
Dietary advice
Growth monitoring
Vermifuge
Vitamin A
39
TUBERCULOSIS
  • Diagnosing TB in children can be difficult.
  • Easy to over-diagnose, but is also easy to miss
    it.
  • Due to immune deficiency, HIV- infected infants
    children are particularly susceptible to TB

40
HIV and TB in children
  • HIV largely responsible for global resurgence of
    TB
  • Children who develop TB are
  • - likely to have negative tuberculin test results
  • more likely to have signs suggestive of TB
    (hepatosplenomegaly, adenopathy, FTT)
  • have more severe TB disease (higher morbidity,
    higher mortality)
  • need longer courses of anti-TB Rx
  • have higher TB drug side effect profile

41
Examination
  • Pulmonary TB
  • No specific findings
  • Extrapulmonary TB
  • Hypersensitivity phenomena (PNT, EN,
    phylectenular conjunctivitis, Poncets arthritis)
  • Non-painful cervical adenopathy fistula
    formation (scrofuloderma)
  • Pleural effusion, especially in adolescents
  • Pericarditis
  • Ascites and abdominal adenopathy
  • Meningism
  • Not responding to antibiotic therapy
  • Subacute onset
  • Gibbus
  • Non-painful, enlarged joint

42
Papular necrotic tuberculid
43
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44
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45
Erythema nodosum
46
Scrofuloderma
47
Diagnosis of TB in childhood
  • Difficult to obtain bacteriological confirmation
  • Need to rely on cluster of suggestive factors
  • - history of positive contact
  • - examination
  • - investigations (PPD, CXR, sputum mcs, Cx, Bx,
    etc.)
  • - need high index of suspicion to Ix
    appropriately make the diagnosis
  • Algorithms (TB scores) useful in guiding decision
    to treat

48
SCORE SHEET FOR TB IN CHILDREN A score of 7 or
more indicates a high likelihood of TB
General feature 0 1 2 3 4
Weeks of illness lt 2 2 - 4 gt 4
Nutrition wt for age gt 80 60 - 80 lt 60
Family history of TB None Reported by family Proved sputum positive
Tuberculin test positive
Malnutrition No improvement After 4 weeks
Unexplained fever ºresponse to Rx
49
Score sheet for TB in children contdTotal
Score for general features Score for local
features
Local feature 0 1 2 3 4
Lymph nodes
Joint /bone swelling
Abdominal mass/ascites
CNS signs, abnormal CSF
Angle deformity of spine
50
TB Treatment and HAART

Potential Problems
  • Increased Pill Burden
  • Overlapping toxities
  • Immune Reconstitution Inflammatory Syndrome
    (IRIS)
  • CYP3A4 induction by rifampicin

51
Two scenarios to consider
  • Child presents with TB pre-HAART
  • Do not delay starting HAART (may only be delayed
    for 1- 2 mo. if not severely immunosuppressed. In
    severe cases - start sooner because of ?
    mortality)
  • If child failed PMTCT (NVP) or is lt3 years old or
    weighs lt10 kg, use Kaletra
  • If child was not given NVP for PMTCT and is gt 3
    years or weighs gt10 kg, use Efavirenz as 3rd drug
  • Monitor ALT monthly if ARV TB Rx given
    concurrently

  • Courtesy of Dr Leon Levin

52
2. Child develops TB while on HAART
  • If child is on Lopinavir/ritonovir (Kaletra) ,
    ritonovir to be boosted (double dose Kaletra is
    no longer recommended
  • If child is on Nevirapine, and is gt3years old and
    weighs gt 10 kg, switch to Efavirenz
  • If child is not tolerating pill burden, discuss c
    paediatrician before interrupting Rx
  • Monitor ALT monthly

53
New Recommendations for the use of Kaletra
(Lopinavir/ritonavir) with Rifampicin (October
2008)
  • Increase dose of Ritonavir such that the dose is
    11
  • (double dose Kaletra results in sub therapeutic
    Lopinavir concentrations and therefore this
    strategy should no longer be used)
  • Practical way to calculate the dose of added
    Ritonavir syrup
  • Calculate the dose (ml) of Kaletra syrup
  • (vWt (kg) X Ht (cm) / 3600 ) X 300 / 80 ml bd
  • The dose of added Ritonavir ¾ of the volume of
    Kaletra
  • Eg If dose of KAL is 2ml bd, the added dose of
    Ritonavir syrup is ¾ x 2ml 1.5ml bd

54
ANTIRETROVIRAL THERAPY
  • Goals of ART
  • To increase survival and decrease HIV related
    morbidity and mortality
  • Childs CD4 count should rise and remain above
    the baseline count
  • Viral load should become undetectable (lt400
    copies/ml or lt25 copies/ml depending on the
    assay) and remain undetectable on ART

55
Requirements for starting ART in children
  • Establish HIV diagnosis
  • Growth monitoring, nutrition immunization
  • Stage the patient - modified WHO
  • Screening CD4
  • Viral load, FBC, LFT(ALT) Depending on the CD4
    levels
  • Treat intercurrent illnesses OIs first.
  • Prophylactic therapy
  • Exclude TB (treat if suspicious)
  • Identify responsible person to administer Rx
  • Counsel educate about ART

56
When to Start Revised 2008 ART Initiation
Criteria
Age Clinical Criteria CD4 ()
lt 1 year WHO 2, 3, 4 (all children who failed PMTCT are at high risk of death and should strongly be considered for ART) lt 1500 (lt35)
1 5 years WHO 3, 4 lt 20
gt 5 years WHO 3, 4 lt 200 (lt15)
57
Other ART Initiation Criteria
  • Recurrent Hospitalization (gt 2 admissions /
    year) or
  • Prolonged Hospitalization for HIV complications
    (gt 4 weeks)
  • Psychosocial Criteria
  • Identified Caregiver
  • Secondary Caregiver highly recommended (not an
    exclusion criterion)
  • Psychosocially ready

58
Psychosocial Criteria (children)
  • At least one identifiable caregiver who is able
    to supervise child or administer medication (all
    efforts should be made to ensure that the social
    circumstances of vulnerable children e.g. orphans
    be addressed so that they too can receive
    treatment)
  • Disclosure to another adult living in the same
    house is encouraged so that there is someone else
    who can assist with the childs ART

59
Treatment of mothers /caregivers
  • Always ask about health of mom and other family
    members
  • Ensure that they access medical care timeously,
    including ART if needed
  • Where possible HIV-positive moms/caregivers
    requiring medical attention should be attended at
    same time (less clinic visits, costs and absence
    from work)

60
Differences between Adults and Children
  • Viral Loads
  • CD4 counts
  • Response to therapy
  • Pharmacokinetics
  • Adherence issues
  • Taste issues
  • Drug formulations and dosing
  • Immune reconstitution

  • Courtesy of Dr Leon Levin

61
Drug Formulations
  • Solutions vs Tablets/capsules
  • Try change to capsules/tablets as soon as
    possible
  • EFV only capsules- disperse contents in jam etc
  • d4T solution- big volumes
  • d4T caps can be dispersed in water stable for
    24 hours at room temp
  • Kaletra capsules Aluvia
  • Palatability
  • Kaletra, Ritonavir

  • Courtesy of Dr Leon Levin

62
  • Storage in fridge
  • 1. d4T solution
  • 2. Kaletra capsules
  • 3. Kaletra solution should be kept in fridge
    until dispensed. Thereafter - stable _at_ room Tº
    for 42 days
  • Dosing in relation to meals
  • empty stomach DDI, EFV
  • Courtesy
    of Dr Leon Levin

63
ADHERENCE
  • Simplicity of Regimen
  • Twice or once daily dosing
  • No food restrictions
  • Medication all taken together
  • Volumes of liquids easy to measure
  • Twice daily does not 12 hourly
  • Choose a regimen that is forgiving of poor
    adherence
  • Education
  • Dont start HAART on first visit
  • Educate whoever is giving the medication
  • Taste issues
  • Monitoring adherence
  • Pharmacy Records
  • Bring Meds to each visit
  • Treatment chart

64
Common stumbling blocks
  • Failure to adjust dosages as child grows
  • Using neonatal dosages in older patients
  • Blindly following guidelines
  • Not checking dosages
  • Changing regimens without resolving adherence
    issues
  • Not consulting an expert

  • Courtesy of Dr Leon Levin

65
Adherence cont ...
  • For good response at least 95 of the ARVs need
    to be taken (Adherence is the key to successful
    therapy)
  • A minority of patients may not respond to ART and
    continue to deteriorate despite good adherence (
    may occur in those who are severely ill before
    starting ART. Underlying OIs should be sought

66
Adherence cont...
  • NB It is essential to ensure that adequate
    levels of drugs are maintained in the body to
    prevent development of resistant strains
  • It is extremely important that patients are
    adherent to their medication

67
Drug Dosing
  • Increase Doses as child grows
  • Body Surface Area (BSA) and weight
  • Dosing Chart
  • BSA formula
  • BSA(m2) weight (kg) x height (cm)
  • 3600

68
BODY SURFACE AREA (BSA) NOMOGRAM
69
BODY SURFACE AREA (BSA) NOMOGRAM
70
BODY SURFACE AREA (BSA) NOMOGRAM
71
Weight Based
Weight Based
72
Monitoring
  • Baseline CD4, Viral Load, (FBC), (ALT)
  • 1-month visit, and 3-monthly clinical exam
  • 6-monthly CD4, Viral load unless indicated
    otherwise
  • Toxicity depending on drug regimen

73
Thapelo before and after
74
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75
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76
Side Effects
  • The same side effects seen in adults occur in
    children.
  • Generally side effects are less common in
    children
  • Some are rare in children, e.g., Stavudine
    related peripheral neuropathy
  • Some are less common in children eg EFV CNS
    effects 14 vs gt 50
  • Some are more common, e.g. EFV-related rash
  • Some occur only in children, e.g.
    Tenofovir-related osteopaenia

77
Immune Reconstitution Inflammatory Syndrome
(IRIS)
  • Paradoxical clinical deterioration, often as a
    result of apparently new or worsening
    opportunistic infections or malignancies, despite
    improvements in surrogate markers of HIV
    infection (virologic, immunological, clinical)
  • May have distinct clinical presentations with
    pronounced inflammatory response
  • Usually within 6 months of starting HAART
  • Usually occurs in those with low starting CD4
    count
  • Causes include- Mycobacterium tuberculosis (MTB),
    BCG, Mycobacterium avium complex, Mycobacterium
    leprae, Cryptococcus neoformans, Aspergillus
    fumigatus, Aspergillus terreus, Candida albicans,
    Pneumocystis jerovici, CMV, JC virus, Human
    Herpes viruses, HSV,VZV, Human Papilloma virus
    and Hepatitis B and C viruses (HBV, HCV).

78
Treatment Failure
Reasons for changing therapy
Failure of current regimen with disease
progression - virologic -
immunologic - clinical Toxicity or
intolerance New data on more effective therapy
MMWR 199847(no.RR-4
79
Treatment Failure
  • Poor adherence
  • Viral resistance
  • Diminished efficacy of ARVs
  • Decreased absorption of ARVs
  • Inadequate dosages
  • Increased metabolism
  • Drug-drug interactions

80
When should treatment be changed?
  • Serious side effect or intolerance
  • Viral load increases (gt 5 000 -10 000 copies/mL)
    or never drops
  • Evaluate and optimise adherence
  • Check dosing
  • Exclude intercurrent infection, OI, drug
    interaction
  • consult an expert
  • Clinical deterioration
  • Exclude IRIS, OI with low CD4 count or TB
  • consult an expert
  • CD4 dropping
  • Exclude intercurrent infection, OI
  • consult an expert

81
Treatment failure cont...
  • Virologic considerations
  • Less than tenfold (1.0 log10) decrease from
    baseline VL after 12 wks of therapy
  • VL not suppressed to undetectable levels after
    4-6 mo. of HAART
  • Repeated detection of VL( gt 5.000 copies/ml) in
    children who initially had undetectable levels in
    response to ART
  • A reproducible ? VL gt 3x (gt0.5 log10) increase
    in childrengt 2yrs and 5fold (0.7 log10 ) increase
    in children lt 2yrs

82
Treatment failure cont...
  • Immunologic considerations
  • Change in immunologic classification
  • For children with CD4of lt15 (Category3), a
    persistent decline from 15 to 10
  • Rapid substantial decrease in absolute CD4
    count

83
Treatment failure cont...
  • Clinical considerations
  • Progressive neurodevelopmental deterioration
  • Growth failure persistent decline in
    weight-growth velocity despite adequate
    nutritional support without any other
    explanation
  • Disease progression - advancement from one
    paediatric clinical category to another( i.e.
    from Cat. A to B )

84
Viral Blips
  • Transient small rises in VL occur in many Pts who
    have achieved full VL suppression
  • They are not thought to be predictors of failure
    provided they
  • - revert to undetectable levels
  • - do not progress

85
Guidelines for Changing ARV regimens
  1. Assess Adherence
  2. Consider Resistance testing
  3. At least 2 new drugs
  4. Preferably 1 new drug class
  5. Dont add one drug to a failing regimen
  6. Consider Cross resistance ?
  7. Consider adding 3TC to maintain M184V mutation
  8. Pharmacokinetic enhancement
  9. Therapeutic Drug monitoring
  10. Structured Treatment Interruptions
  11. Mega- or Giga-HAART
  12. Holding Regimen
  13. New Antiretroviral drugs
  14. Quality of life in end stage disease
  15. Get advice from experienced clinicians

86
Programmatic ART
  • Everyone treated the same
  • Swimming Pool
  • Not everyone can swim
  • Non swimmers need individual attention
  • Dont throw them back in the pool
  • Courtesy of Dr Leon
    Levin

87
HAART and Adolescence
  • Adherence
  • Disclosing Diagnosis
  • Adolescent Groups
  • Courtesy
    of Dr Leon Levin

88
Balancing The Risks

Limiting future options
Progressive Resistance
CONTINUING ON THE SAME FAILING REGIMEN
SWITCHING REGIMENS TOO SOON
89
Practical Resources
  • SA HIV Clinicians Society
  • http//www.sahivsoc.org/
  • sahivsoc_at_gomail.co.za
  • Right to Care Paediatric ARV Helpline
  • 0823526642
  • Dr Leon Levin leon.levin_at_righttocare.org
  • American Guidelines www.aidsinfo.nih.gov
  • PENTA (European) Guidelines   www.ctu.mrc.ac.uk/PE
    NTA
  • WHO Guidelines www.who.intDOH Guidelines
    http//www.doh.gov.za/docs/hiv-f.html

90
References
  • 1. Thanks to Dr Leon Levin Paeditrician, SA HIV
    Clinicians Society
  • 2. Paediatric HIV/AIDS Management Course- Handout
  • 3. DOH Management of HIV infection in children
  • (Guidelines for clinics and hospitals)
  • 4. Handbook on Paediatric AIDS in Africa, 2006
    pg 11
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