Thai national guidelines for the use of antiretroviral therapy in pediatric HIV infection in 2010

Abstract

With better knowledge and availability of antiretroviral treatments, the Thai National HIV Guidelines Working Group has issued treatment guidelines for children in Thailand in March 2010. The most important aspects of these new guidelines are detailed below. ART should be initiated in infants less than 12 months of age at any CD4 level regardless of symptoms and in all children at CDC clinical stage B and C or WHO clinical stages 3 and 4. For children with no or mild symptoms consider CD4-guided thresholds of CD4 <25% (children aged one to five years) or CD4 <350 cells/mm3 (children 5 years or older). The preferred first-line regimen in children aged < 3 years is AZT+3TC+NVP. For children >3 years of age the preferred regimen is AZT+3TC+EFV. If an infant has previously been exposed to NVP perinatally, use AZT+3TC+LPV/r as empirical first regimen. In adolescents, consider TDF+3TC+EFV. The preferred ARV treatment in children who failed first line regimens of 2NRTI+NNRTI (Salvage treatment) comprises 2NRTI (guided by genotype) +LPV/r, and an alternative regimen is 2NRTI (guided by genotype) +ATV/ r (use in cases with dyslipidemia who are six years or older). In cases with extensive NRTI resistance with no effective NRTI option available, double boosted PI with LPV/r+SQV or LPV/r+IDV can be considered. Consultation with an expert is recommended. Laboratory monitoring is recommended for CD4 and every six months. Viral load at least at 6 and 12 months after initiation or change of regimen, then yearly thereafter. More frequent viral load monitoring is advised for cases with unsuccessful virologic response, infants, children with imperfect adherence, or those using of third line regimens. Toxicity monitoring depends on the drug received, at least every six months, and more often as clinically indicated. These include, but are not limited to, complete blood count, renal function tests, liver function tests, urinanalysis, and lipid profiles. Therapeutic drug monitoring is recommended in cases that have ARV-related toxicity, receiving non-standard dosing or regimens, using double boosted PI, and in those with renal or hepatic impairment.

Cost-Effectiveness of Early Infant HIV Diagnosis of HIV-Exposed Infants and Immediate Antiretroviral Therapy in HIV-Infected Children under 24 Months in Thailand

“…The Early-Early strategy reflects the 2010 WHO recommendations for best practice [12]. This is similar to current Thai guidelines which recommend EID and immediate ART in HIV infected children <12-months irrespective of immune/clinical status, although this has not yet been extended to all children <24 months [18].…”

“…The second was on cost-effectiveness of virological monitoring and provision of second line therapy in HIV infected children in Thailand ($3,393 per year of virological failure averted) [52]. The latter is not directly comparable to our study as we assumed that HIV infected children on ART received routine CD4 and virological monitoring every 6 months and had access to second and third line regimen upon treatment failure as per national guidelines [18]. Based on these assumptions, the addition of EID and immediate treatment in all HIV-infected children <24-months was cost-effective, and is likely to be affordable in the Thai setting.…”

Five-Year Trends in Antiretroviral Usage and Drug Costs in HIV-Infected Children in Thailand

“…In addition, we assessed the probability of virological failure defined as: non suppression (viral load (VL) ≥400 copies) after one year of ART in infants or after 6 months in older children; or virological rebound with confirmed VL ≥400 copies after previous suppression as per Thai guidelines 17 . We used the 400 copies/mL over the recommended 50 copies/mL threshold as this was the lower limit of detection of the virological assays during the earlier years of the programme.…”

Pharmacokinetics and Safety of a New Paediatric Fixed-Dose Combination of Zidovudine/Lamivudine/Nevirapine in HIV-Infected Children

“…In Thailand, antiretroviral treatment guidelines have already been modified to include ZDV in the preferred first-line non-nucleoside reverse transcriptase inhibitor-based HAART regimens for children [10]. …”