HIV AIDS Treatment Adult Pediatric Similarities and Differences

HIV/AIDS TreatmentAdult & Pediatric Similarities and Differences Global Health Mini-University October 5, 2007 Objectives      Define Antiretroviral (ARV) Treatment Understand underlying precepts to multi-drug ARV treatment Name the different classes of ARV medications Identify challenges in resource poor settings Differences between adult and pediatric ARV treatment Approach       Retrovirus Lifecycle of HIV Target points in lifecycle Classes of medications Challenges of a public health approach Special challenges facing children Human Immunodeficiency Virus A retrovirus Life cycle Fusion Reverse transcriptase Protease Life cycle Main classes of ARVs 1. 2. 3. 4. Fusion Inhibitors Nucleoside/tide Reverse Transcriptase Inhibitors (NRTIs and NtRTIs) Non Nucleside Reverse Transcriptase Inhibitors (NNRTI) Protease Inhibitors (PIs) Fusion Inhibitors NRTIs NNRTIs PIs Multiple Drug Approach Adult Resource Poor Settings http://www.who.int/hiv/pub/guidelines/WHO%20Adult%20ART%20Guidelines.pdf Pediatric Resource Poor Settings http://www.who.int/hiv/pub/guidelines/WHOpaediatric.pdf Public Health Approach Challenges: Human Resources Infrastructure Supplies Transport Pediatric Challenges Diagnosis  < 18 months    Persistence of maternal antibody No EIA, Western Blot Tests for viral components:    HIV DNA or RNA PCR, Immune Complex Dissociated (ICD) p24 antigen Dried Blood Spots (DBS)  > 18 months  Can use EIA, Western Blot Natural Progression of HIV in Children  If undiagnosed/untreated: mortality by 1 year  50% mortality by age 2  60% mortality by age 3  35% WHO World Health Report 2005 Signs & Symptoms  Often non-specific Respiratory distress  Poor weight gain weight or abnormal growth  Missed milestones in development   crawling, walking and speaking  Poor school performance, seizures, and other symptoms of HIV encephalopathy Challenges     Pediatric expertise and experience Misperceptions that all infected children will die early in childhood Caretaker dependence Drug availability, appropriate formulations at affordable prices http://www.who.int/3by5/en/finalreport.pdf Children and ARV Medications  Delivery Liquid v. solid  Whole, split, crushed, dispensed in water  With or without food  Multiple times per day  Fixed Dose Combinations (FDC)  Children and ARV Medications  Taste  Palatable?  Dosage Growth  Pharmacokinetics  Mg/kg, mg/m2 (BSA), weight bands  From Abrams, El-Sadr and Rabkin: The ICAP Pediatric Clinical Manual, September 2004 Children and ARV Medications  Other Cold chain storage  Toxicities  Adverse reactions  Dependence on a caretaker  Objectives       Define Antiretroviral (ARV) Treatment Understand underlying precepts to multi-drug ARV treatment Name the different classes of ARV medications Identify challenges in resource poor settings Differences between adult and pediatric ARV treatment Similarities/Differences Discussion • • • • • www.usaid.gov www.pepfar.gov www.globalhealthlearning.org http://depts.washington.edu/hivaids/index.html www.who.int/hiv/pub/guidelines/en/