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: crowleys@who.int

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