anti retroviral therapy in children

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ANTI RETROVIRAL THERAPY IN CHILDREN Subhash Chettri

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Post on 27-May-2015

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summary of the latest NACO guidelines for ART in children

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  • 1. Subhash Chettri

2. INTRODUCTION 220,000 children infected by HIV in India 56,700 infected HIV infants added every year One in every six AIDS deaths is a child Children represent only one in every 25 personsgetting treatment in developing countries Only 2,300 children are currently receiving ART inIndiaNACO 2006 3. CASE 1 2 yr and 3 m old Sarojini is HIV positive In the last 6m she has failed to gain wt. and ht. asexpected and suffered from 2 episodes ofpneumonia requiring hospitalisation She also has persistent oral thrush Normal developmental milestones 4. Wt. 8 kg (3rd centile 9.6; 66% of expected) Ht. 75cm (3rd centile 81.9; 85% of expected) Cervical lymphadenopathy Hepatosplenomegaly CD4 count 500/cu. mm 5. Should she be started on ART ? What are the baseline investigations needed? 6. WHO Clinical Staging Stage 1- Asymptomatic or Persistent generalizedlymphadenopathy 7. Stage 2 MildUnexplained persistent HSMUnexplained parotid enlargementPruritic papular eruptionsHerpes zosterExtensive wartsExtensive molluscum contagiosumRecurrent oral ulcersRecurrent or chronic URTI 8. WHO Clinical Staging Stage 3 AdvancedUnexplained moderate malnutritionUnexplained persistent diarrheaPersistent oral candidiasisPulmonary / LN TBSevere recurrent bacterial pneumoniaSymptomatic LIPUnexplained blood cytopeniasBronchiectasisOral Hairy Leukoplakia 9. WHO Clinical Staging.. Stage 4 SevereUnexplained severe wasting / stuntingPCPExtra pulmonary TBEsophageal candidiasisHIV encephalopathyUnexplained severe bacterial infectionsother than pneumoniaChronic herpes simplex infection 10. Extrapulmonary cryptococcosisChronic cryptosporidia or isosporaCMV infectionDisseminated endemic mycosisPMLECerebral or B cell NHLKaposi sarcomaHIV associated nephropathy or cardiomyopathy 11. WHO Immunological Staging 12. WHEN TO START ART? 13. Pre-ART Care 14. Anti Retroviral Therapy Starting ART is not anemergency OIs may be an emergency Stabilize OIs prior to ART Assure responsible care giver It must be emphasised thatonce ART is started, it mustbe taken everyday lifelong Use pediatric formulations 15. Clinical and immunologicalcriteria for starting ART ininfants (< 24m) All infants and children 24m but < 5 yr) All clinical stage 3 and 4 As per CD4 counts 18. CD4 criteria of severe HIVimmunodeficiency24-35m 36 59mCD4% 3 yrsand wt. >10 kgAnd Hb < 9NACO July 2012 25. NRTI backbone NNRTIZidovudine + Nevirapineor + Lamivudine orStavudine + Efavirenz 26. So Sarojini has to be started on ART based on herclinical staging (stage 3) and immunologic staging(severe) 27. Baseline investigations Hb, WBC count X ray chest BU, SE / LFT CD4 count must even if the patient isautomatically eligible for ART due to clinical staging HBsAg / HCV Ophthalmologic examination 28. Case 2 Iqbal, 6yr old HIV +ve boy presented with symptomsof cough and low grade fever for 1m. His father wasrecently detected to have PTB After thorough clinical examination andinvestigations, Iqbal was diagnosed to be sufferingfrom PTB His CD4 count was 195/ cu.mm 29. What is the stage of his disease? What should be started first ATT or ART or bothtogether? If and when ART is started, what drugs should beused? 30. TB and HIV TB and HIV is the commonest coinfectionencountered in India Anti TB treatment should be started immediately.ART should be started 2-8 wks later once ATT istolerated This protocol decreases risk of IRIS 31. Both anti TB drugs and NNRTI drugs (esp NVP)cause hepatotoxicity, therefore close monitoring isnecessary Rifampicin lowers NVP level by 20 to 58% and EFZlevel by 25%. It also lowers serum levels of allprotease inhibitors and should not be coadministered Rifampicin is the best bacteriocidal anti TB drug andmust be the part of anti TB regimen 32. Apart from rifampicin, other anti TB drugs do nothave interaction with ART EFZ is the preferred drug over NVP in patientsreceiving rifampicin (regimens P II and PII (a) shouldbe used) However in children < 3yrs and wt. 9 g/dl 45. Lactic acidosis d4T >AZT Severe nausea, vomiting, abdominal pain ,breathlessness Elevated serum amylase, lactate and liver enzymeswith severe acidosis Liver biopsy shows microvesicular andmacrovesicular steatosis 46. Management Withdraw all ARV drugs Manage symptomatically rehydration, bicarbonateinfusion Mechanical ventilation Symptoms may continue or worsen after withdrawingdrugs 3 to 12 months may be needed for serum lactate toreturn to normal Initiate alternate first line ART 47. IRIS (immune reconstitutioninflammatory syndrome) Collection of signs and symptoms associated withimmune recovery on ART Ability to mount immune response to antigens ororganisms Occurs in 10% of patients on starting ART 25% patients with CD4 24m in stage 1 and 2, initiation of ARTshould be guided by CD4 count 51. AZT +3TC +NVP is the preferred regimen In children with Hb < 9 g/dl, AZT should be replacedby d4T In children >3 yrs and >10 kg on ATT, NVP should bereplaced by EFZ Counselling should be done and adherence shouldbe emphasised on every visit 52. THANK YOU