Description of ARV regimens recommended in ZCG 2020 as preferred first line ART in treatment naive children living with HIV in Zambia

1. Mwango Albert, MDHIVCLINICAL UPDATE
Efficacious ARV regimens for
Children in ZambiaJULY 2020

2. Mwango Albert, MDHIVCLINICAL UPDATE
Disclosures and Disclaimers
• Albert Mwango, BScHB, MBChB, MPH
• I have no conflict of interest or disclosures to declare
• The views, thoughts, and opinions expressed in this presentation
belong solely to me, and do not necessarily reflect the official policy
or position of my current employer –CRS or MOH-Zambia or group
or individual
mwangoaj@gmail.com
2

3. Mwango Albert, MDHIVCLINICAL UPDATE
Outline
• Definitions
• Background
• HIV life cycle & ARV classes
• ARVs resistance from national surveys
• Ideal regimen
• Outcomes of regimens in children
• ZCG 2020 FL regimens

4. Mwango Albert, MDHIVCLINICAL UPDATE
Definitions
• Efficacy: performance under ideal and controlled circumstances
• Effectiveness: performance under 'real-world' conditions
• Potency: amount required to produce a defined effect
• Regimen: structured treatment plan designed to improve and
maintain health
• Recommended regimens for the initial treatment of HIV generally include
a combination of three or more antiretroviral (ARV) drugs from at least
two different HIV drug classes
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5. Mwango Albert, MDHIVCLINICAL UPDATE
Background
• 1.8 million children (<15 yrs) were estimated to live with HIV in 2019
• Treatment coverage remains poor with only 53% of infected children
receiving ART
• HIVDR to NNRTI is as high as 60% as demonstrated by multiple
national surveys
• Almost half of those on ART continue to receive NNRTIs based regimens
• Virological suppression remains poor particularly in younger children

6. Mwango Albert, MDHIVCLINICAL UPDATE
Moz=Mozambique; SWZ=Swaziland UGA=Uganda; ZAF=South Africa; ZIM=Zimbabwe; EFV=efavirenz; NVP=nevirapine; ETR=etravirine; RPV=rilpivirine; AZT=zidovudine;
d4t=stavudine; FTC=emtricitabine; TDF=tenofovir
Jordan MR et al. CID 2017
Resistance in ART naive children < 18 months 2012-2016 (national surveys: Mozambique, Swaziland, Uganda,
Zimbabwe, South Africa)
Overall NNRTI resistance: 53% (50-55)
PMTCT exposure: 56% (51-58)
Unknown: 33% (23-42)
No PMCT: 22% (14-29)

7. Mwango Albert, MDHIVCLINICAL UPDATE
Zambia Peds ART
• Zambia has been
providing ART to
children since 2003
• Out of the estimated
66,000 CLHIV 76%
(50,282) are on ART
7
https://aidsinfo.unaids.org/
© UNICEF/UNI201846/Schermbrucker

8. Mwango Albert, MDHIVCLINICAL UPDATE
HIV Life Cycle
• This a series of seven
steps that HIV follows to
multiply in the body
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9. Mwango Albert, MDHIVCLINICAL UPDATE
Classes of ARVs _Reverse Transcriptase Inhibitor
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Non-nucleoside reverse transcriptase inhibitors (NNRTIs) bind to
and block HIV reverse transcriptase (an HIV enzyme). HIV uses
reverse transcriptase to convert its RNA into DNA (reverse
transcription). Blocking reverse transcriptase and reverse
transcription prevents HIV from replicating.

10. Mwango Albert, MDHIVCLINICAL UPDATE
Classes of ARVs _Protease Inhibitors
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Non-nucleoside reverse transcriptase inhibitors (NNRTIs) bind to
and block HIV reverse transcriptase (an HIV enzyme). HIV uses
reverse transcriptase to convert its RNA into DNA (reverse
transcription). Blocking reverse transcriptase and reverse
transcription prevents HIV from replicating.

11. Mwango Albert, MDHIVCLINICAL UPDATE
Classes of ARVs _Integrase Strand Transfer Inhibitor
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Integrase strand transfer inhibitors (INSTIs) block integrase (an
HIV enzyme). HIV uses integrase to insert (integrate) its viral
DNA into the DNA of the host CD4 cell. Blocking integrase
prevents HIV from replicating.

12. Mwango Albert, MDHIVCLINICAL UPDATE
Recommended Regimen for FL in treatment naïve CLHIV
• a dual- NsRTI/NtRTI
backbone plus an InSTI,
or PI-r or a NNRTI
(anchor drug)
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NsRTI NtRTIOR
InSTI, or PI-r or a NNRTI
PLUS
Backbone
Anchor Drug

13. Mwango Albert, MDHIVCLINICAL UPDATE
Choice of Regimen
13
Efficacy Safety and Tolerability Convenience
Special populations
 HIV/TB
 Pregnant women
 Children/adolescents
 Aging
Access
Cost
Drug Interactions High genetic barrier to resistance

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15. Mwango Albert, MDHIVCLINICAL UPDATE
Outcomes in Children with LPV-r and NVP anchor (1)
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Forest plot of virologic failure or death: nevirapine-based vs. lopinavir/r-based first-line antiretroviral therapy
Penazzato, Martina et al , AIDS28:S137-S146, March 2014Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

16. Mwango Albert, MDHIVCLINICAL UPDATE
Outcomes in Children with LPV-r and NVP anchor (2)
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Penazzato, Martina et al , AIDS28:S137-S146, March 2014Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Forest plot of age sub-analysis for virologic failure or death: nevirapine-based vs. lopinavir/r-based first-line antiretroviral therapy.

17. Mwango Albert, MDHIVCLINICAL UPDATE
INSTI use in children
• Studies in children few
and limited to non-
comparative studies
focusing on safety,
tolerability, and PKs
• Use recommendation
based on results
extrapolated from adult
studies, e.g SPRING-2
17
http://www.arv-trials.com/first_line/eng/comp_INSTI-vs-INSTI/SPRING-2.asp
Original article : Lancet. 2013 Mar 2;381(9868):735-43 - F Raffi, Lancet Infect Dis. 2013 Nov;13(11):927-35 - F Raffi

18. Mwango Albert, MDHIVCLINICAL UPDATE
INSTI use in children extrapolated from SPRING-2 Study
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• DTG 50 mg QD was
virologically non-inferior to
RAL BID
• No INSTI mutations with
DTG
• Safety and tolerability of
DTG similar to RAL

19. Mwango Albert, MDHIVCLINICAL UPDATE
TAF in Children
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Slide credit to samumsf.org

20. Mwango Albert, MDHIVCLINICAL UPDATE
Preferred FL Regimens for CLHIV in Zambia, ZCG 2020
Treatment Naïve no Anti-TB Rx
• <3kgAZT+3TC+NVP
• 3- <20kgABC+3TC+LPV-r
• 20- <25kgABC+3TC+DTG
• 25+ kgTAF+FTC+DTG
20
<3kg 3kg 20kg 25kg 30kg
TLD
TafED
LPV-r
NVP

21. Mwango Albert, MDHIVCLINICAL UPDATE
Preferred FL Regimens for CLHIV with TB
in Zambia, ZCG 2020
Treatment Naïve with Anti-TB Rx
(rifampicin based)
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• <20kg
ABC+3TC+RAL*
OR
ABC+3TC+AZT
• 20-
<30kg
ABC+3TC+DTG*
• 30+ kgTDF+3TC+DTG*
<3kg 20kg 30kg
RAL* or Triple Nukes
DTG*
TLD *
*double frequency of DTG/RAL
TB/HIV

22. Mwango Albert, MDHIVCLINICAL UPDATE
Regimens NOT recommended in children
inferior virologic response & safety issues
• NRTIs only
• NNRTIs
• Un-boosted PIs
• LPV-r dosed OD
• Dual PIs
Rapid resistance, in-efficacy or toxicity
• Monotherapy
• Dual NRTI only
• TDF+ABC+XTC
• Dual NNRTI
• 3TC and FTC combination
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23. Mwango Albert, MDHIVCLINICAL UPDATE
Potential barriers of regimens in Children
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• Barriers
• complex dosing schedules
• using multiple formulations to achieve an appropriate dose
• storage
• palatability

24. Mwango Albert, MDHIVCLINICAL UPDATE
Monitoring of regimens in Children
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• Monitoring
• Viral load
• Adherence
• Weight changes
• CD4 count /percentage
• Kidney and liver function
• Hemoglobin

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