3.30 MB - Academy of Medicine of Malaysia

MANAGEMENT OF HIV INFECTION IN CHILDREN
d) Barriers to ART Adherence
Barriers to adherence among adolescents include those related to development
such as denial, mistrust, rebellion, concrete thinking and other issues such
as fear of disclosure, poor understanding, chaotic lifestyle, substance abuse
and lack of family support. Low self- esteem, depression and feelings of
hopelessness are other common factors.
Efforts need to be focused on reinforcing adherence as described above
and include pillboxes, timers, reminder systems, peer-to-peer adherence
counselling. A lower pill burden, (e.g. co- formulated fixed dose combinations
and drugs with daily dosing (e.g. Tenofovir) and regimens with minimal
adverse effects all facilitate adherence.
e)Transition to Adult Care
Transition is facilitated if adult clinics are in the same facility, and where one
or more providers work in both settings with similar multidisciplinary support.
3.2.5 Treatment failure
Most children can remain stable on HAART for many years. However, at
some point, assessment of the regimen will become necessary. It must be
noted however that the patient’s best response will be to his/her first-line
HAART regimen.
Treatment failure is defined as suboptimal response or a lack of sustained
response to therapy. It can be defined as an inadequate virologic, immunologic,
or clinical response to antiretroviral therapy. It usually begins with virological
213, Level 9
failure, followed by immunological failure and eventually clinical failure.
Careful assessment is required to evaluate the aetiology of treatment failure
and determine the appropriate management strategy. A change in ART may be
considered in a number of different situations, including:
• Suboptimal virologic response to therapy or a sustained increase in viral
load
• Suboptimal immune response to therapy or immunologic deterioration
• Suboptimal clinical response to therapy or clinical disease progression
• Significant drug intolerance or toxicity
• Significant and unmodifiable adherence issues.
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