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Case discussion part I Pediatric HIV treatment initiation

Case discussion part I Pediatric HIV treatment initiation. รศ พญ ธันยวีร์ ภูธนกิจ หน่วยโรคติดเชื้อ ภาควิชา กุมา ร เวช ศาสตร์ คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย HIVNAT, ศูนย์วิจัยโรคเอดส์ สภากาชาดไทย thanyawee.p@hivnat.org 25 กรกฎาคม 2556. Pediatric Case Discussion . Case 1:

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Case discussion part I Pediatric HIV treatment initiation

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  1. Case discussion part I Pediatric HIV treatment initiation รศ พญ ธันยวีร์ ภูธนกิจหน่วยโรคติดเชื้อ ภาควิชากุมารเวชศาสตร์ คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย HIVNAT, ศูนย์วิจัยโรคเอดส์ สภากาชาดไทย thanyawee.p@hivnat.org 25 กรกฎาคม 2556

  2. Pediatric Case Discussion Case 1: When and what to start in infant ? Case 2: When and what to start in children? Case 3: When and what to start in adolescents ?

  3. Case I: 3 month old infant A 3 month old infant presented with interstitial pneumonia with respiratory failure Dx. PCP ANC history: Mother HIV –ve at first trimester, Father: not tested Vaginal delivery, term BW 2,800 gm, breast feeding Mother and Father HIV antibody: positive Infant: CD4 31% (1733 cell/mm3) plasma HIV RNA: 2,600,000 c/ml

  4. Question VOTE Now

  5. Answer

  6. LPV/r vs NVP in children < 3 years Achan J. N Engl J Med 2012;367:2110-8; Palumbo P. N Eng J Med 2010; 363:1510-20; Violari A. N Engl J Med 012;366:2380-9.

  7. Issue on drug formulation • LPV/r syrup: refrigerated, poor taste • Development of 4-in-1 capsule for young children by DNDi LPV/r +2NRTIs granules clinical batch FINAL 4-in-1 2012 2014 2013

  8. Clinical progression

  9. Question VOTE Now

  10. ANSWER

  11. Clinical progression

  12. Take home message Take Home message • HIV-infected infant has high plasma HIVRNA, the best option for treatment is LPV/r-based HAART • Switch to NNRTI-based HAART as a maintenance therapy is encourage in a settings that HIV viral load monitoring is available.

  13. Case II: 6-year old boy A 6-year old boy live with grandparents presented with poor growth, PPE, hospitalized due to pneumonia * 2 times in the past year BW = 18 kg, Ht = 105 cm Anti HIV: positive Hb: 9 mg/dl CD4: 18 % (400 cell/mm3)

  14. Question VOTE Now

  15. Answer

  16. Take home message Take Home message • HIV-infected children should initiate treatment when symptomatic: cat B, C regardless of CD4 and asymptomatic with CD4 < 500 cell/mm3 • EFV has lower risk of virological failure than NVP • Once daily regimen is preferred, however in Thailand; ABC is not yet widely available in the National program

  17. Case III: 15-year old MSM A 15-year old MSM sexually active for 1 year get tested for HIV as a routine check up Anti HIV: positive CD4: 24 % (480 cell/mm3)

  18. Question VOTE Now

  19. HIV incidence in MSM cohort in Bangkok Risk factors: younger age, living alone, drug use for pleasure, receptive anal intercourse, group sex Griensvan F. AIDS 2013,27:825-32

  20. Risk of disease progression by CD4 5-year survival 5-year AIDS free survival Number need to treat = 48 to prevent 1 AIDS event Mortality Hazard ratio CD4 < 350 cell = 1.01 (0.84-1.22) CD4 < 200 cell = 1.20 (0.97- 1.48) AIDS-illness Hazard ratio CD4 < 350 cell = 1.38 (1.23-1.56) CD4 < 200 cell = 1.90 (1.67- 2.15) HIV-causal collaboration: Ann Intern Med 2011; 154:509-14

  21. Hazard ratio of tuberculosis by CD4 at time of initiation HR 0.43 (0.30-0.63) Suthar AB. PLOS 2012; 9: e1001270

  22. Take home message Take Home message • Behavioral risk HIV-infected adolescents will increase over the years, esp in MSM • Decision to initiate ART should balance between disease progression risk/ risk of HIV transmission, and readiness of patient • Should address adherence and risk of develop of drug resistance • Once daily regimen with high genetic barrier might be an option.

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