3.30 MB - Academy of Medicine of Malaysia

intercurrent infections. 196, Level 6 A recent study by Nettles et al 193, Level 6 suggested
that these blips signify random biological and statistical variation around
mean HIV-1 levels below 50 copies/mL rather than clinically significant
elevations in viremia.
j) Immunologic Monitoring
The majority of patients (adults, children and adolescents) on HAART will
197, Level 6; 140, Level 6; 198, Level 6; 199,
show improvements in CD4 counts and percentages.
Level 6 197, Level 8 Among adults a plateau appears to be reached by 4 years while
the study on children 198, Level 6 showed that improvements in CD4 continued
throughout the second year follow-up.
There is little information on the expected rate of improvement among
children. However, the younger the age and the lower the pre-treatment
CD4 the greater the improvements. Thus an increase of 10% or more at 6
months of treatment was seen among children younger than 2 years of age
where median time to achieve CD4 > 30% (pre-treatment CD < 25%) was
less than 12 months in one study. 198, Level 6 This study also demonstrated the
mean CD4 increase at 6 months was 9% with inter-quartile ratio 4-13%.
Recommendation for monitoring
MANAGEMENT OF HIV INFECTION IN CHILDREN
Clinical monitoring (pVL)
• Children on HAART should be evaluated clinically for adherence, drug
adverse effects and improvements in weight, height and development.
(Grade C)
Virologic monitoring
• Plasma viral load (pVL) should be monitored at week 8, week 12 and
every 4-6 months thereafter or whenever there is a clinical event or
significant decline in CD4+ T cells. (Grade C)
• Therapy is considered adequate if pVL declines by at least 1 log 10*
by week eight and optimally to < 50copies/ml by week 24-32. In those
not achieving viral suppression, a sustained decrease in HIV RNA
copy number of 1.5 to 2.0 log 10 from baseline (if achieved RNA
levels are low) may also be considered adequate. (Grade C)
Immunologic monitoring
• CD4 should be monitored 3-4 monthly for patients on HAART. (Grade C)
- CD4 is expected to increase in the majority of children with
increases in CD4% ranging from 5-10% at 6 months with
continued rise through first 2-3 years of HAART.
- Patients with discordant responses (no increase in CD4 despite
viral load suppression, or improved CD4 but with continued
high pVL) should be referred to paediatric infectious diseases
specialist.
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