This document discusses the management of HIV/AIDS in children through antiretroviral therapy (ART). It covers introductory concepts of ART including viral dynamics in children, drug classes, and clinical classification of HIV in children. The goals of ART are to enhance quality of life by restoring immune function, improving symptoms, and reducing morbidity and mortality through durable viral suppression. Critical issues in ART include adherence, combination therapy, and nutrition. Indications for starting ART are based on clinical stage and laboratory findings such as CD4 count. Monitoring of ART includes viral loads, CD4 counts, growth, and drug interactions. Recommended first-line and second-line ART regimens for children of different ages are provided.

1. Management of HIV/AIDS in
Children: Antiretroviral
Therapy (ART)
Dr. James Chipeta
Department of Paediatrics and Child Health
School of Medicine
University of Zambia
Lecture to 7th Year 2005

2. Lecture Overview
• Introductory Remarks: Basic Concepts in ART
- Viral Dynamics in Children & ART in children
- The HIV and ART Drug Classes
- Classification of HIV in Children
• ART in Children
- Goals of Therapy
- Critical Issues (Adherence; Combination therapy;
Nutrtion)
- Indications for ARTs
- Initiation of Therapy
- Monitoring of ARTs (Viral Loads; CD4 counts; Growth monitoring; Drug
interactions,etc)
• Recommended ARV regimens in Children
- Children Under 3 months
- Children over 3 months

3. Introductory
Remarks: Basic
Concepts in ART

4. Viral Dynamics in Children
and ART in children
ART in Children
• ART is becoming the standard
care for HIV world wide
• ART in Children is highly
specialised venture
• Role of Paediatrician or such
specialised health workers for
optimum benefit from ART
• ART in CHhildren is generally
as in adults but it is far behind
in experience
• Fewer therapeutic options in
children
• A number of children specific
features make ART in children
unique compared to adults
Viral Dynamics in children
• Due to their immunophysiology
viral loads in children are far
much higher in their first year
of life and decline by 5—6
years
• By 2 months most infants have
viral loads more than 100 000
RNA copeis/ml plasma (0-
million copies/ml plasma)
• Mean viral load in infancy is
185 000 copies/ml
• Generally the higher the viral
load the more rapid the
disease progression

5. Baseline CD4% and HIV viral Load
and Risk of Deaths
VIRAL LOADS
(copies/ml)
BASELINE
CD4%
PATIENTS
(N)
DEATHS
(%)
<100 000 >15 103 15
<15 24 63
>100 000 >15 89 36
<15 36 81

6. The HIV and Classes of ART Drugs
Non-
Nucleoside
Reverse
Transcriptas
e Inhibitors
(NNRTI)
Fusion
Inhibitors
(FI)
Nucleoside
Reverse
Transcriptase
Inhibitors
(NRTI)
Protease
Inhibitor
s (PI)

7. ARV CLASSES
ARV CLASS DRUG SIDE EFFECTS
NRTI AZT;
Stavidine (d4T)
Abacavir
Lamivudine (3TC)
Didonosine (ddT)
Anaemia;granulocytopaenia;LA
Headache;rash;GE;Pn,Panc/titis
Atopy;nausea;GITs;lymphopaenia
Headache;fatigue;Panc/titis;Pn
Abd pain;GIT;Panc/titis;Pn
NNRTI Neverapine
Efavirenz
Rash;Sedative effects;GIT;L/toxic
Skin rash;CNS-Sleep;
PI Ritonavir (RTV)
Nelfinavir (NFV)
GIT;Hypercholesterolaemi;Hpergly
ceridaemia
GIT;L/Toxic;
Hypercholesterolaemi;Hperglyceri
daemia
FI Enfuvirtide ?
RI Hydroxyurea (HU) Grancytopaenia,Anaemia
(WITHDRAWAN0

8. WHO Clinical Classification of HIV
in Children (Revised 2005)
STAGE SIGNS AND SYMPTOMS
I •Asymptomatic
•PGL
II •Papular pruritic eruptions
•Hepatosplenomegaly
•Seborrhoeic dermatitis
•Extensive HPV
•Extensive molluscum Contagosum
•Fungal nail infections
•Recurrent oral thrush
•Lineal gingival erythema
•Angular cheilitis
•HZoster
•Recurrent or chronic URTI (OM,Sinusitis)

9. WHO Clinical Classification of HIV
in Children (Revised 2005)
STAGE SIGNS AND SYMPTOMS
III •Moderate unexplained malnutrition
• Unexplained PPD (14 days or more)
•Unexplained Persistant fever
•Oral candidiasis (outside neonatal period)
• Hairy leukoplakia
•Acute necrotising ulcerative gingivitis/periodontis
•PTB
•Severe recurrent Pneumonia
•LIP
•Unexplained Anaemia(<8g/L), and or thrombocytopaenia (<50
000/m3),and or Neutropaenia (<1000)
•Chronic HIV associated lung Disease (e.g. Bronchiectasis)

10. WHO Clinical Classification of HIV
in Children (Revised 2005)
STAGE SIGNS AND SYMPTOMS
IV •Un explained severe wasting or Malnutrition not respeonding to therapy
• PCP
•Recurrent presumed bacterial infections (e.g. empyaema,meningitis,etc)
•Chronic HSV infections (> 1 month)
• Extrapulmonary TB
•Kaposi’ Sarcoma
•Oesophangeal candidiasis
•CNS Toxoplamsosis (outside neonatal period)
•HIV encephalopathy
•CMV infection
•Extrapulmoanry Cryptococcosis (including meningitis)*
•Cryptosporidiosis

11. ART in Children

12. Goals of Therapy
Overral goal is to enhance
quality and quantity of life
and promote physical,
social and intellectual
development. Hence
even in the absence of
ARV aim at;
• Good supportive care
• Aggressive treatment of
intercurrent infections
• Provision of nutrition
support
• Prevention of
opportunistic infections
Specific ART goals`are
thus;
• Restoration or Prevention
of Immunolgical function
• Improvement in clinical
symptoms
• Reduction in Morbidity
and Mortality
• Maximal and durable
suppression of viral load

13. Critical Issues ARTs
• Adherence
• Combination therapy
• Nutrition

14. Indications for ARTs
When to start treatment: Clinical Basis
• STAGE IV:Treat all children irrespective of Laboratory
findings
• STAGE III
>18 months: Treat irrespective of CD4
>18months: Treat guided by CD4
• STAGE II: CD4 Guided or Total Lymphocyte
• STAGE I: Only Guided by CD4 counts if not available do
not initiate ART

15. Indications for ARTs
When to start treatment: Laboratory basis

16. Monitoring of ARTs
• Viral Loads
• CD4 counts
• Growth monitoring
• Drug
interactions,etc

17. Recommended ARV
regimens in Children (WHO): First
line Drugs or What to start with

18. Recommended ARV
regimens in Children (WHO):
Second line Alternatives