Session 2 Pediatric ART basics udom-chas.pptx

Regime in treatment of paediatric AIDS

1. Session 2: Paediatric ART

2. Learning Objectives By the end of this session, participants are expected to: Describe aspects to check before initiation of ART Describe ARV regimens for children Explain reasons for changing ARV in children Describe adherence in ART treatment to Children Explain psychosocial support for children on ART

3. Initiation of ART The general criteria for initiating ART states that: All HIV infected individuals regardless of age clinical stage, CD4 level, HIV risk group, pregnancy status, associated comorbidities are eligible for ART

4. Initiation of ART in children Age When to start All HIV infected children Treat all regardless of WHO clinical stage or CD4 cell count/percentage Children below 18 months who qualify for presumptive diagnosis: ( symptomatic children with WHO stage 3 or 4 conditions and has a positive rapid test(antibody test)) Start ART while waiting for confirmation by DNA-PCR

5. ART Initiation Checklist Step Check 1 Has HIV testing been confirmed with a repeat-test, on a different sample, ideally by a different health care worker? Or in case of a single tester, has the repeat test been done on a different sample? 2 Does the client have sufficient understanding about HIV and ART, and is the client psychologically ready to start ART? 3 Screen for TB. 4 Ensure all OIs and other infections have been screened for (cryptococcal disease if CD4 <200; TB; STI) and treated according to appropriate national guidelines 5 Perform a thorough physical examination of the client

6. ART Initiation Checklist Step Check 6 Review the results of the baseline laboratory tests 7 Discuss the choice(s) of ARV regimen with the client 8 Review with the client, the potential side effects of the medication 9 If all of the above steps have been checked and the client is willing and ready, initiate ART 10 Enter the client in the Pre and ART registers

7. Recommended 1st line ARV regimens (1)- Pediatric Age Weight Preferred first line Justification Alternative Comments Infant ≥ 4 weeks 3-5.9Kg ABC+3TC + pDTG   ABC+3TC+ LPV/r (syrup)     6-9.9Kg ABC+3TC +pDTG   ABC+3TC+ LPV/r(granules)     10 – 19.9Kg ABC+3TC + pDTG DTG Lowers HIV viral load very fast, has high genetic barriers to resistance compared to both PIs and NNRTIs ABC+3TC + LPV/r (granules/ tabs)   In Special Circumstances: AZT+3TC + LPV/r (granules/tabs) Choice of granules or tabs depends on ability to swallow

8. Recommended 1st line ARV regimens (2)- Pediatric Age Weight Preferred first line Justification Alternative Comments   20 – 29.9Kg ABC+3TC+DTG -DTG Lowers HIV viral load very fast -Has high genetic barriers to resistance compared to both PIs and NNRTIs ABC+3TC + LPV/r (granules/tabs)     In Special Circumstances: AZT+3TC +LPV/r AZT+3TC +DTG AZT should as much as possible spared for subsequent lines

9. Recommended 1st line ARV regimens (3)- Pediatric Age Weight Preferred first line Justification Alternative Comments   ≥ 30Kg TDF+3TC+DTG -Higher genetic resistance barrier -Avoids NNRTI transmitted resistance from mother during PMTCT   TDF+3TC+EFV 400/600   ABC+3TC+ LPV/r ABC+3TC + DTG     In Special Circumstances: AZT+3TC +LPV/r AZT+3TC +DTG Switching of ART will depend on prior exposure.   AZT should as much as possible be spared for subsequent lines

10. Recommended 1st line ARV for coinfected children (TB/HIV) ( 1) Age Weight Preferred first line Justification Alternative Comments   For TB/HIV co-infection already on DTG ABC+3TC +DTG (if above 20Kg double the dose of DTG 50mg.   If <20Kg, double the dose of pDTG (one dose in the morning and one dose in the evening). Continue with ABC+3TC+DTG but the dose of DTG should be doubled.     AZT should as much as possible be spared for subsequent lines

11. Recommended 1st line ARV for coinfected children (TB/HIV) ( 2) Age Weight Preferred first line Justification Alternative Comments   For TB/HIV co-infection already on LPV/r ABC or AZT+3TC +LPV/r(double the dose of LPV/r) Continue with ABC+3TC+LPV/r but the dose of LPV/r should be doubled due to the interaction between ritonavir and rifampicin       For TB/HIV co-infected on TLD TDF+3TC+DTG   Continue with the same regimen, Double dose of DTG   TLD in the morning and only DTG (50 mg) in the evening

12. Recommended Pediatric 2 nd Line ARVs regimens (1) Patient age Patient weight If is on the following first line Preferred 2 nd Line Alternative 2 nd line regimen Comments Infant ≥ 4 weeks 3-5.9Kg ABC+3TC +pDTG AZT+3TC +LPV/r (syrup)       6-9.9Kg ABC+3TC +pDTG AZT+3TC +LPV/r (granules)       10 – 19.9Kg ABC+3TC +pDTG AZT+3TC +LPV/r       20 – 29.9 Kg ABC+3TC+DTG AZT+3TC +LPV/r AZT+3TC +ATV/r (if weight ≥ 25Kg  

13. Recommended Pediatric 2 nd Line ARVs regimens (2) Patient age Patient weight If is on the following first line Preferred 2 nd Line Alternative 2 nd line regimen Comments   ≥ 30Kg TDF+3TC+DTG AZT+3TC +ATV/r   AZT+3TC +LPV/r ABC+3TC +ATV/r ABC+3TC +LPV/r  

14. Recommended Pediatric 2 nd Line ARVs regimens (3) Patient age Patient weight If is on the following first line Preferred 2 nd Line Alternative 2 nd line regimen Comments   For TB/HIV co-infection already on DTG ABC+3TC +DTG (if above 20Kg double the dose of DTG 50mg;   If <20Kg, double the dose of pDTG (one dose in the morning and one dose in the evening). AZT+3TC +LPV/r (Double the dose of LPV/r)    

15. Recommended Pediatric 2 nd Line ARVs regimens (4) Patient age Patient weight If is on the following first line Preferred 2 nd Line Alternative 2 nd line regimen Comments   For TB/HIV co-infection already on LPV/r ABC + 3TC +LPV/r If < 20Kg give AZT+3TC+ LPV/r (double dose LPV/r)  If ≥ 20Kg AZT+3TC+DTG (Double the dose of DTG)         If ≥ 30Kg TDF+3TC+DTG (Double the dose of DTG)       For TB/HIV co-infected on TLD TDF+3TC+DTG   AZT + 3TC + LPV/r ABC+3TC+LPV/r  

16. Recommended pediatric 3 rd Line ARVs regimens Patient weight Preferred third Line Comments Children < 20Kg pDTG+DRV+RTV+AZT+3TC DRV+RTV: High genetic barrier; effective for patients with resistance to LPV/r, ATV/r. Cannot be used in children <3 years Children ≥ 20Kg DTG+DRV+RTV+AZT+3TC

17. Assessment of infants and children on ART

18. Changing ARV in Infants and Children Following are major reasons for changing ARV Therapy in children and adolescents:- Drug Toxicity Change of guidelines Treatment failure Virological failure Immunological failure Clinical failure

19. Adherence in ART Treatment to Children (1) Children have unique adherence issues Most of child’s adherence to HIV medications is dependent upon another individual Factors that influence adherence for children: Drug regimen: taste, dosing and volume Health status of child: common childhood illnesses and mood Patient-care giver-clinician relationship: non- friendly clinic environment for kids; poor communication and understanding

20. Adherence in ART Treatment to Children (2): Reported Difficulties Taking ARV Medications Taste/Palatability/Pill burden: Difficulties with unpleasant flavour and/or smell Nausea Too many pills Social Situations – Fear of disclosure: Visiting or out with friends Visiting relatives over weekend Visitors in house Had to leave child with a friend for the day

21. Adherence Issues in ART Treatment to Children (3): Factors Associated with Adherence Demographic variables: Age, sex, Caregiver type, caregiver sex Income Disclosure to child, to others Stress Stigma Caregiver factors: Child communication Self-efficacy Health beliefs Depression

22. Indication that a child needs psychosocial support Silence/poor communication by and with adults Non-disclosure, insensitive disclosure Bereavement, multiple losses, and consequences Stigma and discrimination Dealing with chronic ill health, pain and discomfort Exclusion from the care process Looking and feeling different from others Watching and caring for a terminally ill parent Abuse (physical, sexual and social) esp. orphans Aspects

23. Psychosocial Support to children on ART Psychosocial support may include: Follow up of progress at school Provide support to caregivers to enable them to provide care, support and guidance to children Capacitate caregivers on disclosure process Offer adequate educational and developmental opportunities Address stigma Link clients with Legal support according to needs Discrimination, abuse, exploitation, inheritance rights Manage illnesses, offer support in dealing with death and bereavement

24. Five A’s in Providing Psychosocial Support Assess psychosocial needs of child and caregiver Advise on how to address the needs Agree on activity plan to address the needs Assist caregiver to understand how to carry out activities in plan Arrange actions to carry out plan: Referrals, linkages Appointments and follow-up meetings

25. Questions or comments on this session? Chapter 4: HIV Prevention Service for Adolescents

26. Key Points Reasons for changing ART are drug toxicities, change of guidelines and treatment failure Assess infants and children progress at every visit Manage illness and offer psychosocial support according to needs