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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. 39
DEFINITIONS OF TREATMENT FAILURE Virological failure: 46, Level 9 MANAGEMENT OF HIV INFECTION IN CHILDREN Incomplete viral response to therapy • Reduction in plasma HIV RNA of less than 0.5 log10 four weeks after • initiation of therapy, and less than 1.0 log10 reduction at eight weeks.* Failure to suppress plasma HIV RNA to undetectable levels within six months of treatment initiation* Viral rebound • Confirmed rebound viraemia after initial reduction to undetectable levels (i.e.repeated detection of HIV RNA >400 copies/mL.)* • Confirmed >0.5 log10 (greater than 3-fold) increase in HIV RNA copy number for children age >2 years or >0.7 log10 (greater than 5-fold) increase for children age
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3.30 MB - Academy of Medicine of Malaysia

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