HIV in Children

ANTIRETROVIRAL THERAPY

Dr. Ira Shah
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Last Updated: 7th November 2013
Although implementing ART is complex, a number of guidelines are available to help practitioners’ select effective regimens for particular patients. The decision to start ART depends on clinical, immunological and socioeconomic conditions. There are US guidelines, Penta guidelines, (World Health Organization) WHO guidelines and NACO (National AIDS Control Organization) guidelines that help in determining treatment protocols. There guidelines are regularly updated as and when newer research on treatment protocols and newer ARVs are available. The clinician treating HIV infected children should thus be aware of the latest treatment guideline. A comparison of when to start ART as per PENTA guidelines, WHO guidelines and US guidelines are depicted in Table 2.

Table 2:

Comparison of current PENTA, WHO and US treatment thresholds



  PENTA 2009 US 2010 WHO 2010
0–11months
Clinical
Immunological
Virological
Treat all Treat all Treat all
12-24 months
Clinical

Immunological [CD4%/count]

Virological
Treat CDC Stage B or C/WHO stage 3 or 4

Treat <25% or <1000 cells/mcL

Consider >100,000 copies/mL
Treat CDC Stage B or C


Treat <25%

Treat >100,000 copies/mL
Treat all
24–35 months
Clinical

Immunological [CD4%/count]

Virological
Treat CDC Stage B or C/WHO stage 3 or 4


Treat <25% or <1000 cells/mcL

Consider >100,000 copies/mL
Treat CDC Stage B or C


Treat <25%

Treat >100,000 copies/mL
Treat WHO Stage 4 and severe 3


Treat <25% or <750 cells/mcL
36–59 months

Clinical

Immunological [CD4%/count]

Virological
Treat CDC Stage B or C/WHO stage 3 or 4


Treat <20% or <500 cells/mcL

Consider >100,000 copies/mL
Treat CDC Stage B or C


Treat <25%

Treat >100,000 copies/mL
Treat WHO Stage 4 and severe 3


Treat <25% or <750 cells/mcL
5 years+
Clinical

Immunological [CD4%/count]

Virological
Treat CDC Stage B or C/WHO stage 3 or 4


Treat <350 cells/mcL

Consider >100,000 copies/mL
Treat CDC Stage B or C


Treat <350 cells/mcL

Consider >100,000 copies/mL
Treat WHO Stage 4 and severe 3


Treat <15% or <350 cells/mcL

Before antiretroviral therapy is started, it is essential that parents, care-givers and patients are counseled regarding the importance of adherence to the prescribed treatment regimen. The goal of therapy should ensure normal growth and development, avoiding opportunistic infections and organ dysfunctions due to HIV and maintaining as healthy and normal life style as possible. Antiretroviral therapy is never an emergency and potential problems should be identified and resolved prior to starting therapy.

WHO guidelines 2013:

The major shift in the 2013 WHO guidelines for antiretroviral therapy (ART) in children from previous recommendations is that it should be initiated in all children infected with HIV below five years of age, regardless of WHO clinical stage or CD4 cell count. Also recommended is that ART should be initiated in all HIV-infected children five years of age and older with CD4 cell count ≤500 cells/mm3, regardless of WHO clinical stage. But again, these recommendations are conditional because of the lack of evidence, however, this approach is expected to provide a high coverage of pediatric ART.

ANTIRETROVIRAL THERAPY
Dr. Ira Shah
Incharge Pediatric HIV and TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India Consultant in Pediatric Infectious Diseases, Nanavati Hospital, Mumbai, India.
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