managements of hiv

8/13/2019 Managements of HIV

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HIV IN CHILDREN

MANAGEMENT AND TREATMENT

Pope Kosalaraksa, M.D.

Department of Pediatrics

Faculty of Medicine

Khon Kaen University, Thailand


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HIV MANAGEMENT

Management HIV-infected

infant >> toddler >> children >> adolescent >> adulthood

Antiretroviral therapy

: Children and Caregivers

: Holistic care by multidisciplinary team

: Health Well being


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ANTIRETROVIRAL TREATMENT (ART)

Combination drug regimens

: effectively suppress viral replication in most patients

> 3 drugs from at least 2 drug classes

Reduction in opportunistic infections and other

complications of HIV infection

Improved growth and neurocognitive function

Enhance survival

Improved quality of life in children


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Currently Ultimate Goal of HAART

Relative

Levels

MonthsYears After HIV Infection

CD4+ T-cells

Plasma HIV Viremia

Acute HIV infection Symptom

Limit of detection
http://www.iasusa.org/


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PEOPLE RECEIVING ART: 2003-2012

WHO Global update on HIV treatment 2013

WHO 3 by 5 campaign

9.7 million by 2012

630,000 children

0.3 million at 2002

WHO 2015 Target

15 million on Treatment

4.2 million AIDS death

averted from ART


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CHILDREN (0-14YR) RECEIVINGART BY 2012



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NEWPEDIATRIC HIV CASE: 1996-2012


2015 Target

Elimination of HIV PMTCT

> 90% of pregnant women received ART

800,000 new pediatric HIV

has been averted during

2005-2012

2015


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ANTIRETROVIRAL DRUGS

NNRTINRTI


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FRAMEWORK OF HIV TREATMENT AND CARE


ENTRYPOINTS

PED

ARVCLINICS

UNDERSTANDDYNAMICS


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WHEN TO START ?

WHO treatment guideline 2013

HIV functional cure: Mississippi Baby


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WHEN TO START: WHO GUIDELINE 2013

AGEGROUP

2010 RECOMMENDATIONS


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INFANT < 3 MO: EARLY TREATMENT LOWERAIDS/DEATH

CHER trial CIPRA South Africa; Violari A. NEJM 2008;359:2233-44.

Death: 4% versus 16% (HR = 0.24, p


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CHILDREN: WHEN TO START ?

PREDICT trial1 (1-12 years, RCT n=300)

AIDS-free survival did not differ between deferred (CD4


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WHAT TO START ? WHO 2013

Age group 2013 recommendations

< 3 years PI LPV/r is preferred NVP as alternative

2 NRTIs ABC+ 3TC or AZT +3TC

3-10 years NNRTI EFV is preferred NVP as alternative

2NRTIs In preferential order:

ABC + 3TC or

AZT + 3TC or TDF + FTC (3TC)

10-19 years

(weighing35 kg)

NNRTI EFV is preferred NVP as alternative

2NRTIs In preferential order:

TDF + FTC or 3TC

ABC + 3TC

AZT + 3TC


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FUNCTIONAL CURE:AMISSISSIPPI BABY

30 hours

HIV DNA+

AZT/3TC/NVP

started on day 1

AZT/3TC/LPV/r

from day 7

Persaud D, 2013 Oral late breaker, Abstract 48LB

HIV RNA

Loss to follow up

and stop ARTat age 18 months


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EVALUATION BEFORE STARTING ART

1) Medical evaluation

Diagnosis and treat opportunistic infection

If CD4


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EVALUATION BEFORE STARTING ART

2) Children and caregiver preparedness

Provide correct knowledge and attitude about HIV and ARV

(side effect, storage, administration)

Reason to take ARV (age appropriate)

Time to take ARV: child and caregiver activities

Correct practice in different situation

: forgot to take, delay, traveling, stand by ARV

3) Adherence preparedness


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DRUG DEVELOPMENT: MONTHLY INJECTABLE ART

GSK 744

HIV integrase inhibitor/ dolutegravir analogue

Injectable nanosuspension; IM SC

Achieve plasma concentration > 4 times IC90 in healthy adults

TMC-278 LA

Long-acting nanosuspension of rilpivirine (NNRTI)

IM loading 1200 mg then maintenance 600 mg q 4 week

Plasma level comparable to oral rilpivirine 25 mg/day

Spreen W. IAS 2013 WEAB0103


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TE M MEETING


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OPD


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C REGIVER GROUP CTIVTY


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C REGIVERGROUP CTIVITY


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PH RM CIST ND TE M


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CONFERENCE FTER CLINIC


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HOME VISIT


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HOME VISIT


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HOME VISIT


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HOME VISIT


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C MP


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C MP


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C MP


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Thank you


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CHILDREN: EFV VERSUS NVP-BASED ARTBotswana-Baylor retrospective cohort HIV-infected children 3-16 years (N= 804)

Median age 8 years, CD4 = 13%, Plasma HIV RNA = 5.3 log10

copies/ml

NRTI backbone: AZT/3TC 92% F/U time 69 months

VL failure at 5 year

EFV = 12.8%

NVP = 25.1%

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