Paediatric HIV Myanmar

8/6/2019 Paediatric HIV Myanmar

1/27

uav;oli,frsm;udk ARV aq;

wdkufauR;jcif;ESifhjyKpkapmufa&Smufjcif;;

Prepared By: Dr.Wut Yi Soe


2/27

uav;oli,frsm;udk ART wif&mwGif

vdkufem&rnfh tcsufrsm;

START

(yxr tqifh aq;? &dK;&Sif;aom enf;vrf; jzifh p&ef)

SUBSTITUE

(aq;rwnfh vQif yxr tqifh aq;xJrS om ajymif;&ef)

SWITCH

(aq;,Of oGm;vQif rl 'kwd, tqifh aq; odkhajymif;&ef)

SALVAGE/STOP


3/27

Vitoria, 2005

2 NRTI + 1

NNRTI

Start Substitute

1st Line

2 NRTI + 1

PI/r

Switch

2nd Line

PI/PI/r or strategic

recycling old drugs or

new ARV regimens

with 2nd

generationdrugs

Salvage

Salvage Stop

Lab Monitoring NeedsPill BurdenToxicity/Drug InteractiDrug CostReferral / Mentoring ne


4/27

START

rnfonfhtcsdef wGif aq; p oif. oenf;/

rnfonfregimen ESifh poifh oenf;/


5/27

ART p&rnfh Criteria

Clinical criteria (a&m*g vuPmpkrsm;)

Immunological criteria (CD4 tajc tae)

Virological criteria(Viral load tajc tae)


6/27

Immunological assessment: CD4

1994 Revised Human Immunodeficiency

Virus Pediatric Classification

< 1year 1-5 year 6-12 year All age group

Immunologic category

1. no suppression >1500 >1000 >500 >25%

2. moderate 750-1499 500-999 200-499 15-24%3. severe


7/27

Infants

1. Initiate ART for all HIV-infected infants diagnosed inthe first year of life, irrespective of CD4 count

or WHO clinical stage.

(uav; arG;uif;p rsm;wGif (1) ART udk touf wpf ESpf twGif; HIVydk;&dS onf [k owfrSwfxm;aom uav;rsm;udk ay;oifh onf/)


8/27

Children

2. Initiate ART for all HIV-infected children between 12and 24 months of age irrespective of CD4

count or WHO clinical stage. (uav;rsm;wGif (2) ART udk touf wpfESpf rS ESpfESpf twGif; HIV ydk;&dS onf [k owfrSwfxm;aomuav;rsm;udk ay;oifh onf/)

3. Initiate ART for all HIV-infected children between 24and 59 months of age with CD4 count of 750 cells/mm3

or %CD4+ 25, whichever is lower, irrespective of WHOclinical stage.(touf 2 ESpf rS 5 ESpf twGif; CD4 count of750 cells/mm3 or %CD4+ 25 rSm pyg/ clinical stageudk tav; rjykygESifh)


9/27

4. Initiate ART for all HIV-infected children more than 5years of age with a CD4 count of 350 cells/mm3 (as inadults), irrespective of WHO clinical stage.

(5 ESpf txuf qdk vQifCD4 350 atmuf qdk vQif ay;Edkif onf/) 5. Initiate ART for all HIV-infected children with WHO

clinical stages 3 and 4, irrespective of CD4 count.

(Clinical stages 3 and 4 qdkvQif aq;ay;Edkif onf/)


10/27

6. Initiate ART for any child less than 18 months of agewho has been given a presumptive clinical diagnosis ofHIV infection.

(18 v atmufHIV/AIDS vuPm rsm;awG.vQif ay;oifhonf/)


11/27

What to start recommended first-line ART regimens forinfants and

(yxr tqifh aq;? &dK;&Sif;aom enf;vrf; jzifh p&ef)


12/27


Infants (arG;uif;p uav;rsm; twGuf)

1) rdcif rS PMTCT twGufART raomuf ao;vQif

(2 NRTI s + NNRTI)2) rdcif rS PMTCT twGufART aomuf jyD;vQif

(lopinavir/ritonavir (LPV/r) + 2NRTIs)

3) aq;aomuf jyD;^rjyD; raocsmvQif(2 NRTI +NNRTI)


13/27


Children(uav;rsm; twGuf)

1) touf 12 v rS 24 v txd uav; rsm;wGif rdcif onfPMTCT rS ARTaomuf xm;vQif(lopinavir/ritonavir (LPV/r) + 2

NRTIs)

2) touf 12 v rS 24 v txd uav; rsm;wGif rdcif onfPMTCT rS ARTraomuf xm;vQif(2 NRTIs + NNRTI)

3) 24v ESifh 3ESpf Mum; qdkvQif(NVP + 2 NRTIs)3ESpfatmufwGifEFVrokH;&

4) 3 ESpf ESifh txuf qdkvQif(NVP/EFV + 2 NRTIs)

5) arG;uif;pInfants or childrentwGuf (2 NRTIs +NNRTI)rSm

Lamivudine (3TC) + zidovudine (AZT) or 3TC + abacavir(ABC) or 3TC + stavudine (d4T)


14/27


Infants(arG;uif;p) ESif. uav; rsm; twGuf txl;tajctae

touf3 ESpf ESifh txuf tuberculosis (TB) &SdvQifEFV + 2NRTIs regimen ay;oiHfhonf/

touf3 ESpf atmuf tuberculosis (TB) &SdvQifNVP + 2NRTIs regimen ay;oifhonf odkh a triple nucleosideregimen.

uav; rsm;ESifh tysdK? vlysdK azmf 0if t&G,f

aoG;tm;enf;vQif(


15/27

aq;tnTef; (Austrillia)


16/27

aq;tnTef; (NAP Guide line)

Zidovudine (AZT)= 10 mg/kg/dose twice daily

Stavudine (d4T)= 1mg/kg/dose twice daily

Lamivudine(3TC)= 4mg/kg/dose twice daily

Nevirapine (NVP)=7mg/kg/dose twice daily(8 yrs old)Initial once a day for 2 week

Efavirenz (EFV)= (only for the children over 3 years)

10-


17/27

Uav;rsm; twGufvlMuD;aq;

rsm;udk csdK;wdkufjcif;

aumif;udsK;

vG,fulpGm&Edkif onf/

qdk;udsK;

wdusrIr&dS

BUT in many situations we have no choice!

decision to use adult FDC tablets in children (>1012 kg)


18/27

Adult FDC tablets can successfully beAdult FDC tablets can successfully begiven to children who urgently needgiven to children who urgently need

HAART in resourceHAART in resource--limited settingslimited settings (RLS).(RLS).

OBrien DP et al AIDSOBrien DP et al AIDS 20062006


19/27

ypnf;ud&d,mrsm; ESifh toHk;jyKyHk


20/27

BWBW((kgkg))

GPOvirGPOvirdosagedosageQQ 1212 hrhr

66--88 11//44 tabtab

99--1111 11//22 tab,tab, 11//44tabtab

1212--1717 11//22 tabtab1818--2424 33//44 tabtab

>> 252511

tabtab

d4T 30 mg3TC 150 mgNVP 200 mg

1 cm


21/27

d4T+3TC+EFV

BWBW dd44TT 33TCTC EFV*EFV*

(kg)(kg)

((3030mm

g)g)QQ 1212hrhr

((150150mgmg

))QQ 1212hrhr

((5050,, 200200

mgmg))QD hsQD hs

1212--11

44 cacapp

tab tab200200 mgmg

1515--11

77250250 mgmg--

Lamivudine

(150 mg)

stavudine

(30 mg)

efavirenz

1 cm.

(50mg)

(200 mg)


22/27

yxr 6 v wGif Munfh&rnf

tcsufrsm;(on ART)prepration 1-2 Mo 3-4Mo 4-6 Mo

CounsellingSS(ESpfo dr faq G;aEG;jci f;)

ARVside effect(q dk;u sKd;)

Monitoring efficacy(aq ;\ x da&mu fr I)

Opportunistic infection(OI)

Immune Reconstitution Syndrome(IRIS)

Adherence monitoring


23/27

ART rpcif ESpfodrfaqG;aEG;jcif;

ARV aq;udk rnfodk aomufrnfenf;

rnfolujyKpkapmifha&Smuf rnfenf;/

Adherence a&m*g vuPm rsm;awGvQif aq;cef;odk jyefvm&ef

tjzpfrsm;aom aq;qdk;usKd;rsm;udkajymjy xm;&ef

aq;cef;odk. rSefrSef jyefvm&ef? woufvHk;

aomuf&aomaq; jzpfaMumif; ajymjy&ef Uav;\ touf t&G,f ESifh tajctae t& zGifh[ajym qdkjcif;

twGuf pOf;pm;&ef


24/27

Ttjzpfrsm;aom ARV qdk;usdK;rsm;

Symptoms ARV Timin

gPrevalence

Substitut

ions

Rash(teDjyif) NVP

EFV

2-4

week

2-4week

20-

30%

5-10%

EFV, PI

NVP, PI

Nausea, vomiting (rl;?tef) AZT 1-4

week

5-10% d4T

Night mare,

headahce(tdyfrufqdk;ruf?acgif;udkuf)

EFV 1-2

week

20-

30%

NVP

Anemia(aoG;eDOeJ) AZT 4-8 5-10% d4T


25/27

aq;ay;jyD;aemuf uav;udk apmihfMunf.ukojcif;

aq;ay;jyD; yxr v wGif 1 ywf 1 cg csdef;yg/

'kwd, v wGif 2 ywf 1 cg csdef;yg

6 v txd 1 v 1 cg csdef;yg

6 vaemufydkif; wGif3 v 1 cg csdef; yg

uav; aeraumif;vQif &uf pdyfpdyf csdef;yg


26/27

CD4 change after ARV %

5

11

13

16

21

2425 26

155

350

395

492

699745 759

718

0

5

10

15

20

25

30

35

40

0 8 24 48 72 96 120 144

Week of ART

CD4percen

tag

0

100

200

300

400

500

600

700

800

CD4cellco

un

CD4 percentage CD4 cells


27/27

Growth change after receive ARV

Documents

Paediatric HIV Myanmar