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MANAGEMENT OF HIV INFECTION IN CHILDREN 3. MANAGEMENT OF HIV INFECTED INFANTS, CHILDREN AND ADOLESCENTS Management of HIV-1 infected children requires monitoring of disease progression, timely commencement of a potent HAART regimen, monitoring of treatment, assessing response and adverse reactions. 3.1 MONITORING DISEASE PROGRESSION Monitoring of disease progression of the HIV-1 infected child is through clinical, immunological and virological means. 3.1.1 Clinical There are two major systems for clinical classification of HIV infection in children: the WHO Clinical Classification and the CDC Classification System. The guideline development group has chosen to adopt the WHO classification for Malaysia (refer Appendix 1 and 2). 3.1.2 Immunologic Immunologic monitoring is done by serial evaluations of the CD4 lymphocyte count and percentage. HIV associated immunodeficiency is defined as not significant, mild, advanced and severe according to age-related cut-off values of CD4% and count (refer Appendix 3). 3.1.3 Virologic Virologic monitoring is by the use of plasma viral load (pVL) assays. Current R methods used are the Roche Amplicor HIV-1 Monitor System - standard R and ultrasensitive and the Roche COBAS Taqman HIV-1 . The lower limits of detection vary with the type of assay (Amplicor standard
HAART has been shown to provide the following benefits: 134, Level 9 ;135, Level 6 ;136, Level 6 ;137, Level 6 ;138, Level 6 139, Level 6 ;140, • Reduce mortality by 67-80%. Level 6 • Halt progression to AIDS by 50%. 139, Level 6; 140, Level 6; 136, Level 6 However, Doerholt 135, Level 6 found no change in progression to AIDS in young infants. 134, Level 6 ;135, Level 6 ;137, Level 6; 141, Level 6 • Reduce hospitalization rate by 68-80%. However, Bertolli 141, Level 6 noted a slight increase in hospitalisation in those on HAART, but this association was not noted when analysis was restricted to more recent years (1997-2002). • Reduce incidence of opportunistic and related infections by 62-93% 142, Level 6 , 143, Level 6;144, Positive impact on child growth and psychomotor development. Level 6 3.2.2 When to initiate therapy MANAGEMENT OF HIV INFECTION IN CHILDREN When to start ART in children remains controversial. The only RCT (PREDICT study) investigating the initiation of HAART therapy has just started recruiting participants. In the absence of evidence from RCTs, recommendations on when to start combination therapy in children (and adults) are based on cohort data that provide an estimate of the risk of progression to AIDS or death based on surrogate markers of infection (i.e. the child's CD4 % and pVL). An important meta-analysis, 145, Level 1 of individual data of 3941 children from 17 studies in Europe and US demonstrated short-term risks (12 months) of progression to AIDS or death at different ages based on child's presenting CD4% and pVL, with the former being the stronger predictor (Appendix 3). Progression to AIDS or death also differs according to age, with infants and young children having a significantly higher risk. In addition, both CD4% and pVL are poorly predictive of disease progression in infants
Page 2 and 3: This Guideline is intended a guide
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Page 8 and 9: REVIEW COMMITTEE The draft guidelin
Page 12 and 13: TABLE OF CONTENTS MANAGEMENT OF HIV
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71 Appendix 2 WHO CLINICAL STAGING
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MANAGEMENT OF HIV INFECTION IN CHIL
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Appendix 6 MANAGEMENT OF HIV INFECT
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Appendix 7 MANAGEMENT OF HIV INFECT
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