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Pediatric Antiretroviral Therapy in HIV-Infected Children - Guidelines & Adherence Tips

Learn about criteria for ARV initiation, dosing strategies, adherence techniques, and case studies for pediatric HIV treatment. Comprehensive guide from HAIVN at Harvard Medical School in Vietnam.

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Pediatric Antiretroviral Therapy in HIV-Infected Children - Guidelines & Adherence Tips

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  1. Antiretroviral Therapy in HIV-infected Children HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants should be able to: • Outline criteria for starting an HIV+ child on ARVs • Identify first line ARV regimens for children in Vietnam • Describe how to prepare ARV doses for children based on age, weight, and BSA • Propose recommendations to improve ARV adherence in children

  3. Diagnosis of HIV Infection in Infants and Children • The earlier the better! • Early diagnosis, and early ART, greatly reduce mortality • All PLWHA with children should be encouraged to test their children for HIV • Diagnostic protocol is divided into 3 age groups: • 0-18 months • 9-18 months • > 18months

  4. Flow Chart for PCR Testing in Infants < 9 Months First PCR at 4-6 weeks of age – + – Second PCR as soon as possible + Child is infected with HIV ELISA at 18 months If infant is breastfeeding, repeat PCR after infant has stopped breastfeeding for 6 weeks

  5. Diagnosing Children 9 to 18 Months and > 18 Months • For children 9-18 months: • Perform ELISA first • If positive, perform PCR as for children under 9 months • If negative, repeat ELISA at 18 months • If breastfeeding, stop for 6 weeks before ELISA testing. If ELISA positive, perform PCR • For children >= 18 months: • Perform ELISA

  6. Cotrimoxazole Preventive Therapy

  7. Cotrimoxazole Prophylaxis (1)

  8. Cotrimoxazole Prophylaxis (2) • Discontinuation: • Alternative therapy: • If allergic to cotrimoxazole, use dapsone 2mg/kg/day once a day (100mg pill)

  9. Indications for the Initiation of ARV Therapy

  10. Classification of Immunodeficiency

  11. Criteria for ART Initiation

  12. First-line ARV Regimens In case of intolerance to AZT, change to ABC. If there is contraindication of ABC, use d4T

  13. ARV Regimens Co-administered with TB Drugs Rifampicin lowers NVP levels; it’s preferable to use EFV when possible

  14. ARV Dosing

  15. Two common ways: Weight-band dosing Body Surface Area (BSA) ARV Dosing for Children *Weight and height should be recorded at every visit

  16. Stavudine and Lamivudine

  17. Zidovudine (AZT)

  18. Nevirapine (NVP)

  19. Efavirenz (EFV)

  20. D4T Fixed Dose Combinations (FDC)

  21. AZT Fixed Dose Combination (FDC)

  22. Preparing ARVs for Children Use syringe to measure drugs. Do not use cups Syringes that can be snugly connected to the bottles can be used to draw up the exact amount of medication needed.

  23. Pediatric ARV Monitoring • Clinical • Physical growth, nutritional status - use growth chart • Development – neurologic, cognitive, social, psychological • Social • Support for caretakers • Evaluate adherence to PCP prophylaxis and/or ARV

  24. Laboratory Monitoring

  25. Case Study 1 • 19-month-old HIV positive child is eligible for ART • His weight is 6 kg • Write a correct prescription for this child using a d4T-based regimen

  26. D4T-Based Regimen: Weight 6 kg Initial 14 days: Lead-in dose, Use individual drugs Then, change to FDC:

  27. Case Study 2 • 4 year old HIV positive child is eligible for ART • His weight is 18 kg • Write a correct prescription for this child using a AZT-based regimen

  28. AZT-Based Regimen: Weight 18 kg Initial 14 days: Lead-in dose, Use individual drugs Then, change to FDC:

  29. Case Study 3 • 6 year old HIV positive child, weight 22 kg • Has pulmonary TB and is on TB treatment • Write a correct prescription for this child using a AZT-based regimen

  30. AZT and EFV - Based Regimen: Weight 22 kg Use EFV for patients on TB therapy (> 3 years old and ≥ 10 kg)

  31. Adherence Techniques for Children

  32. Adherence for Missed Doses 3 Steps to Address “Missed Doses” Clarify the history with the caretaker Suggest solutions FollowupAdherence

  33. Missed Doses: Clarify the History with Caretaker Question to clarify: • WHAT medicine(s) were missed ? • HOW many dose(s) were missed ? • WHEN were the dose(s) missed ? • WHO was responsible to deliver the medicines ? • WHY did the caretaker think it happened ?

  34. Missed Doses: Suggested Solutions (1) Hard to take medicines:

  35. Missed Doses: Suggested Solutions (2) Ways for caretaker to remember to give the medicine to the child: • Pick an event that is easy to link the medicine to • Give family a pill-box for tablets, when appropriate • Suggest they use an alarm clock for alerting when taking the medicines

  36. Missed Doses: Follow up Adherence Schedule a time for counseling staff to check adherence with the family and make plans for ongoing adherence support by: • Phone calls • Clinic visits • Home-care visits

  37. Key Points • ARVs can be initiated in a child with a confirmed HIV infection • Preferred first line regimen in children is same as in adults: AZT/3TC/NVP • All medications in children are dosed according to child’s age and weight • Good pediatric adherence requires a team approach

  38. Thank you! Questions?

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