Starting children and infants on ART;
what do the guidelines say?Dr Siobhan Crowley
Paediatric & Family HIV Care Department of HIV/AIDS
World Heath Organization,Email: [email protected]
http://www.who.int/hiv/paediatric/en/index.html
WHO recommendations • Published within adult guidelines in 2003• Stand alone August 2006 • Include dosing instructions (Annex E) • Review meeting April 2008
http://www.who.int/hiv/paediatric/generictool/en/index.html
http://www.who.int/hiv/pub/guidelines/art/en/index.html
April 2008 –Technical Reference group meeting
For infants panel reviewed:
• When to perform virological testing
• When to start ART• What ARVS to start in
infants with HIV
WHO strongly recommends:
all infants under 12 months of age with confirmed HIV infection should be started on ART, irrespective of clinical or immunological stage
:
What ART to Start in infants –2008 revision
No infant or maternal
ARV exposure
MTCT ARV Exposure
Sd NVP or NNRTI containing ART
Non NNRTI exposure
Unknown infantmaternal MTCT
Exposure
NVP triple ART
PI triple ART#
NVP triple ART
NVP triple ART
# If no PI is available use NVP triple ART
Mum 34%Baby 18%
Children 1 year or over Clinical and/or
immunological criteria to start ART
Standard first line regimen
NNRTI + 2NRTI
< 3 years NVP + AZT
+ 3TC
> 3 years EFV + AZT
+ 3TC
Standard second line regimen
PI + 2 new NRTI
Summary PATIENT GROUP PREFERRED FIRST LINE
REGIMEN PREFERRED SECOND LINE REGIMEN
INFANTS
Infant not exposed to ARV NVP + 2 NRTI LPV/r + 2 NRTI
Infant exposed to NVP Boosted PI + 2NRTI NNRTI + 2NRTI
Infant with unknown ARV exposure
NVP + 2 NRTI LPV/r + 2 NRTI
CHILDREN
Children 3 years or over NNRTI + 2NRTI Boosted PI + 2 NRTI
ADULT OR ADOLESCENTS
Adult or adolescent NVP + 2 NRTI Boosted PI + 2 NRTI
Revised simplified dosing
Acknowledgments & resources: • HIV Care Technical Reference group • Paediatric ARV dosing working group:
– Tony Nunn, Ed Caparelli, Shaffiq Essajee, Mark Mirochnick & Diana Clarke
Meeting report summarising these recommendations http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdfProceedings of the meeting http://www.who.int/hiv/pub/meetingreports/art_meeting_april2008/en/index.html2006 guidelines (being updated to reflect above) http://www.who.int/hiv/pub/guidelines/art/en/index.htmlTool to assist in developing dosing recommendations http://www.who.int/hiv/paediatric/generictool/en/index.htmlA programming guide – how to scale up Paed care and treatment: http://www.who.int/hiv/paediatric/Paeds_programming_framework2008.pdf
Paediatric HIV care landing page http://www.who.int/hiv/paediatric/en/index.html