HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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402 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 4.4.2. Continuing exposure due to maternal ART during breastfeeding • Although some ARVs (NVP, ZDV and 3TC) are known to be present in breast milk, the concentration and quantity ingested by infants is less than therapeutic levels (41, 42). • If a breastfeeding infant is ill enough to require ART, the administration of ARVs at standard paediatric doses should be initiated, regardless of whether the mother is receiving ART. • The standard 2 NRTIs + 1 NNRTI first-line regimen is recommended. 4.5. ARV dosage and age-dose adjustment Every three months, the ARV drug dosage should be checked and adjusted according to the child’s weight; otherwise, there is a risk of underdosing and developing resistance. Doses are calculated either on a milligram per kilogram body weight or milligram per square meter body surface basis. Standardization is important, so that non-expert personnel can safely dispense and/or check correct dosages for children. It is sensible clinical practice to round up doses into easier doses for the parents. It is better to overdose by up to 10% as the child rapidly grows. For ARV dosages please refer to Annex 3 (30). 4.6. Adherence Adherence is the key to achieving an effective clinical, immunological and virological response to ART, and it should be no less than 95% of the prescribed dosage (23, 43, 44). An initial intervention strategy to improve adherence is described in section III.3 above on counselling of caregivers, and adherence monitoring is described in section III.5.5 below. Medication strategies to improve adherence include: • choosing the simplest regimen, with a lower dosing frequency and number of pills; • prescribing carefully to avoid drug interactions; • simplifying food requirements for administration of medication; • informing patients and caregivers of possible side-effects, and anticipating and treating side-effects; and • using the best-tasting liquid medication if possible, and introducing tablets as soon as feasible or if liquid medication is not available. 4.7. ART failure Poor adherence, inadequate ARV dosage or potency (23, 43, 45, 46) and pharmacokinetic problems (47) can all contribute to treatment failure. Children should have been taking their first-line regimen for at least 24 weeks and adherence deemed adequate before treatment failure is suspected. The clinical criteria for treatment failure should be supported with immunological (CD4) criteria. 4.7.1. Immunological failure In treatment failure, children on ART persist at or below the age-related CD4 threshold for initiating treatment (see Table 2 above). Failure is characterized by an initial immune recovery after initiation of ART, followed by a drop in CD4 measurements to values at or below their age-related threshold for initiation of treatment. Previous CD4 values are thus needed to define treatment failure using immunological criteria. 4.7.2. Virological failure The definition of virological treatment failure is more complex, and consensus on it has not yet been reached. The overall aim of treatment is to reduce VL to levels below the lowest detection threshold (
Paediatric HiV/aidS treatment and care 4.7.3. Clinical failure The following are considered indicative of treatment failure: • development of new or recurring Stage 3 or 4 events (see Annex 1) at least 24 weeks after initiation of a first-line regimen; • lack of or decline in growth rate in children who show an initial response to treatment, despite adequate nutritional support and without other explanation; • loss of neuro-developmental milestones (presence of two or more of the following: impairment in brain growth, decline in cognitive function and clinical motor dysfunction (48)); and • new opportunistic infections, new malignancies, recurrence of refractory oral candidiasis or recurrence of oesophageal candidiasis. Clinical disease progression should be differentiated from immune reconstitution inflammatory syndrome (IRIS), please see section III.5.3. 4.8. Second-line ART regimens The entire regimen should be changed from a first-line to a second-line combination only in the event of immunological or clinical failure after 24 weeks of treatment. The new second-line regimen should include at least three new drugs, one or more of them from a new class, in order to increase the likelihood of treatment success and minimize the risk of cross- resistance, and it should be based upon drugs that retain activity against the patient’s viral strain (see Table 5). The advantages of PI-based regimens include proven clinical efficacy and well-described toxicities. Because of the diminished potential of almost any second-line nucleoside component, a low-dosed RTV-enhanced PI (PI/r) component is recommended. Table 5. Second-line art for infants and children Preferred second-line ART regimen First-line ART regimen at failure NRTI/NNRTI components PI component + a 2 NRTIsa + 1 NNRTI Containing ABC + 3TC + (+NVP or EFV) ZDV + ddIb LPV/rd or SQV/re or NFVf ABC + 3TC ZDV + ddIb Triple NRTI ddI (ZDV + 3TC + ABC) b + EFVc or NVP aContinuation of 3TC in the second line may be considered. bShould not be taken on an empty stomach. cEFV is not recommended for children
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HIV/AIDS TREATMENT AND CARE Clinica
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© World Health Organization 2007 A
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iv Acknowledgements The editors wou
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vi Marco Vitoria (WHO headquarters)
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viii CRP C-reactive protein CS caes
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x LFT liver function test LGE linea
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xii TDM therapeutic drug monitoring
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xiv Introduction HIV is a chronic i
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Annex 7. Glossary .................
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HIV/AIDS TREATMENT AND CARE CLINICA
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HIV/AIDS TREATMENT AND CARE CLINICA
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10 HIV/AIDS TREATMENT AND CARE CLIN
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1 HIV/AIDS TREATMENT AND CARE CLINI
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I. Principles management of opportu
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management of opportunistic infecti
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Table 8. pcp second-line treatment
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Table 12. oesophageal and dissemina
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5.9.1.2. Treatment Table 15. treatm
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palliative care for people living w
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III. Initial evaluation palliative
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IV. Treatment palliative care for p
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Fig. 2. who analgesic ladder for ma
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Type of pain or treatment Usual sta
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Table 5. prevalence of symptoms in
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Type Symptoms Possible causes Disea
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Type Symptoms Possible causes Disea
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Table 22. Management of mania and B
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Table 24. Management of cough or di
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V. Special advice for terminal care
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Table 27. common manifestations in
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References palliative care for peop
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VI. Suggested minimum data to be co
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136 HIV/AIDS TREATMENT AND CARE CLI
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Contents I. Policy and principles .
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I. Policy and principles HIV/AIDS T
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HIV/AIDS TREATMENT AND CARE FOR INJ
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° bacterial pneumonia ° endocardi
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Social factors are: • homelessnes
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Table 3. Interactions between ARV d
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Other medications Use Rifampicin (R
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Table 5. Interactions of illicit dr
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ANNEX 1 ASI6 C © 2004 University o
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• Cardiovascular Hypertension Tac
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Contents I. Epidemiology and natura
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ManageMent of Hepatitis C and HiV C
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Annex 3. Alcohol screening question
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Table 16. a sample of the drug pipe
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3.2. Considerations regarding treat
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278 hiv/aids tReatment and caRe cLi
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I. Prevention strategies Prevention
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Prevention of HePatitis a, B, C and
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Prevention of HePatitis a, B, C and
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5. Contraceptive methods for women
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454 hIv/aIds tReatment and caRe clI
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Contents I. Policy issues .........
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I. Policy issues post-exposure prop
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post-exposure prophylaxis for hiv i
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° condom use ° presence of STIs (
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Table 3. thre- drug arv regimens Pr
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VI. Suggested minimum data to be co
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History of antiretroviral treatment
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Test results: HBV: HCV: HIV: Post-t
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Infection control standard precauti
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The World Health Organization (WHO)
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