agenda introduction- jessica rodrigues, iatt paediatric treatment optimization- george silberry,...
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Agenda• Introduction- Jessica Rodrigues, IATT• Paediatric Treatment Optimization- George Silberry, Senior
Technical Advisor for Pediatric HIV, OGAC• Optimal regimen selection and sequencing- Elaine Abrams Senior
Director for Research, ICAP• Optimal formulation selection- Marc Lallemant Head of Pediatric
HIV, DNDi and Janice Lee Project Manager for Pediatric HIV, DNDi• Optimizing supply chain management- Nandita Sugandhi, Senior
Clinical Advisor, CHAI and Marianne Gauval Associate Director of Pediatric Access, CHAI
• Q&A/Discussion- Surbhi Modi, Maternal and Infant HIV Team Lead, CDC
2013 WHO RecommendationsFirst-line Antiretroviral Regimens
Children < 3 years Children 3 years to < 10 years
Adolescents > 10 years
Preferred ABC + 3TC + LPV/r or
AZT + 3TC + LPV/r
ABC + 3TC + EFV TDF + 3TC + EFV
Alternative ABC + 3TC + NVPAZT + 3TC + NVP
ABC + 3TC + NVPAZT + 3TC + EFVAZT + 3TC + NVPTDF + 3TC (or FTC) + EFVTDF + 3TC (or FTC) + NVP
AZT + 3TC + EFVAZT + 3TC + NVPTDF + 3TC (or FTC) + NVP
At program level generally fewer choices are available:• Simplifies guidance for health care workers• Streamlines procurement and supply chain
Choosing a Preferred Pediatric First Line
• Effective• Safe• Forgiving• Easy to take• Easy transition as children
grow
Children < 3 years
Children 3 years to < 10 years
Adolescents > 10 years
Preferred ABC + 3TC + LPV/r Or
AZT + 3TC + LPV/r
ABC + 3TC + EFV
TDF + 3TC + EFV
Life-long Treatment: Rational Sequencing of Regimens Starting in Childhood
• Objective to achieve simplified recommendations harmonized across all age groups
• Rational sequencing of drugs and drug regimens for a public health approach • From first to second to third line• From infancy to adulthood
• Considerations for guidance for regimen transitions as children age into adulthood
Rational sequencing of NRTI’s
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AZT
d4T
ABC
TDF
Thymidine Analogs
Cytidine Analogs
Thymidine analogs may be MORE effective after failure on cytidine analogs; cytidine analogs may be LESS potent after thymidine analog failure and accumulation of TAMS
frRational Sequencing of NRTI’s
First-line Determines Second-line
WHO, 2013
Simplifying Second-line ART
Challenge Solution
Low recognition of treatment failure
Expanded use of VL for routine monitoring
Currently used 2nd line regimens don’t support adherence
Simpler options are available (e.g. ATV/r for older children)
Confusion about what to use after LPV/r failure in 1st line
Introduction of new agents: Raltegravir >4weeks, dolutegravir >12 yrs, darunavir for >3 years
Raltegravir • Dosing established in pediatrics for ≥ 4 weeks of age• Pediatric formulations available:
– Powder for suspension for <10kg– Chewable tab for >10kg
• Twice daily dosing• RTG dosing with TB co-treatment
under study• Currently limited availability• Limited interest for adults
Good option but not favourable for harmonization
Dolutegravir
• Low dose/kg is good for infants and children• High genetic barrier ideal for poorly adherent children and
adolescents• Once daily dosing and good toxicity profile • Only approved for ≥12 years of age• Dispersible formulation in development• Not FDC ready yet and only planned in
combination with abacavir• Ongoing and planned studies for children :
IMPAACT 1093 & ODYSSEY
Ideal for harmonization but not yet a reality
Third-line ART for Children: Is a Public Health Approach Possible?
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Challenge SolutionIndividualized regimens based on resistance pattern
New guidance from WHO based on rational sequencing and availability of new drugs
Cost Affordable options should become available with increasing demand
Availability in RLS Programs are beginning to plan for introduction of third-line
(New Horizons)
Third-line ART for Children: Is a Public Health Approach Possible?