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MANAGEMENT OF HIV INFECTION IN CHILDREN As there is limited evidence with regards to salvage therapy, no definite recommendations can be provided and these patients should be referred to the Paediatric Infectious Diseases Specialist. Recommendation for salvage therapy • Salvage treatment is treatment reserved for children who have already received and failed two or more regimens. Refer to Paediatric Infectious Disease specialist for further management. (Grade C) Resistance testing or genotypic testing The prevalence of resistance in children who had failed HAART and had virological failure is high ranging from 71% to 90%. There is a close relationship 214, Level 6 ;215, Level 6 between therapeutic failure and genotypic resistance. Ideally genotypic resistance assays should be carried out in children failing therapy. These assays should be obtained when the patient is still on the failing regimen or within 4 weeks of discontinuation of the regimen and while the patient has a pVL of > 1000c/ml. If resistance testing is not carried out, a sample should be stored for subsequent analysis. Some reports in children have shown genotypic resistance testing to be useful for guiding therapy particularly for children with extensive ARV experience. 46, Level 9 Recommendation for resistance testing ARV drug resistance testing* is recommended prior to changing therapy for treatment failure. (Grade B) Resistance assays* should be obtained when the patient is still on the failing regimen or within 4 weeks of discontinuation of the regimen and while the patient has a pVL of > 1000c/ml. (Grade B) * This test is currently not available for clinical purposes When to stop ART If children have failed multiple ART regimens and no further suitable ARVs are available, stopping ART and keeping them comfortable with symptom-based 154 Level 9 palliative care may have to be considered. These children may experience undue suffering from psychological problems, pain, diarrhoea, cough, shortness of breath, nausea, weakness, fatigue, fever and confusion. Palliative care aims at relieving pain, treating the above symptoms, providing psychological support for patient and family and helping them with preparation for death. (Refer to palliative care 216, Level 9 ; 217, Level 9 guidelines). 43
3.2.6 Management of medication toxicity or intolerance • If a child has severe or life-threatening toxicity, all components of the drug regimen should be stopped immediately. Once the symptoms of toxicity have resolved, antiretroviral therapy should be resumed with substitution of another antiretroviral drug for the responsible drug. • Children with moderate medication toxicity should continue on antiretroviral therapy when possible while an assessment is done to identify and substitute for the offending agent. • Children with mild toxicity can be treated symptomatically, and do not require drug discontinuation or change in drug therapy. • When changing therapy because of toxicity or intolerance to a specific drug, changing a single drug in a multi-drug regimen is permissible; if possible, an agent with a different toxicity and side 46, Level 9 effect profile should be chosen. 3.2.7 Short-term therapy interruption MANAGEMENT OF HIV INFECTION IN CHILDREN • Short-term interruptions of ARV drugs may be indicated in some situations such as serious treatment-related toxicity, acute illness or surgery. • When short-term interruptions are required, then all antiretroviral drugs should be stopped at the same time, if these medications have similar half-lives. • However when agents with long half-lives are used (especially the NNRTIs EFV and NVP) cessation of all ARVs simultaneously could result in functional monotherapy with risk of resistance to these agents. To prevent functional monotherapy, some experts recommend stopping the NNRTI component first and continuing the other ARV drugs for a period of time (the optimum duration still not known - WHO recommends a one-week tail of the NRTI drugs). • In case of serious or life-threatening ARV therapy toxicity, all drugs should be stopped immediately. 44
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This Guideline is intended a guide
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MANAGEMENT OF HIV INFECTION IN CHIL
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Page 8 and 9: REVIEW COMMITTEE The draft guidelin
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3.30 MB - Academy of Medicine of Malaysia

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