uav;oli,frsm;udk ARV aq; wdkufauR;jcif;ESifh jyKpkapmufa&Smufjcif;;

Prepared By: Dr.Wut Yi Soe

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; odkh ajymif;&ef) SALVAGE/STOP

1st Line Start Substitute

2nd Line Switch 2 NRTI + 1 PI/r

Salvage Salvage Stop

2 NRTI + 1 NNRTI

PI/PI/r or strategic recycling old drugs or new ARV regimens with 2nd generation drugs

Lab Monitoring Needs Pill Burden Toxicity/Drug Interaction Drug Cost Referral / Mentoring need Vitoria, 2005

START

rnfonfhtcsdef wGif aq; p oif. oenf;/ rnfonf regimen ESifh poifh oenf;/

ART p&rnfh Criteria Clinical criteria (a&m*g vuPm pkrsm;) Immunological criteria (CD4 tajc tae) Virological criteria(Viral load tajc tae)

Immunological assessment: CD4

1994 Revised Human Immunodeficiency Virus Pediatric Classification

<1year 1-5year 6-12year A agegroup ll Im unologiccategory m 1. nosuppression >1500 >1000 >500 >25% 2. m oderate 750-1499 500-999 200-499 15-24% 3. severe <750 <500 <200 <15%

 Infants 1. Initiate ART for all HIV-infected infants diagnosed in the 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; HIV ydk;&dS onf [k owfrSwfxm;aom uav;rsm;udk ay;oifh onf/)

 Children 2. Initiate ART for all HIV-infected children between 12 and 24 months of age irrespective of CD4 count or WHO clinical stage. (uav;rsm;wGif (2) ART udk touf wpf ESpf rS ESpfESpf twGif; HIV ydk;&dS onf [k owfrSwfxm;aom uav;rsm;udk ay;oifh onf/) 3. Initiate ART for all HIV-infected children between 24 and 59 months of age with CD4 count of 750 cells/mm3 or %CD4+ 25, whichever is lower, irrespective of WHO clinical stage.(touf 2 ESpf rS 5 ESpf twGif; CD4 count of 750 cells/mm3 or %CD4+ 25 rSm pyg/ clinical stage udk tav; rjykygESifh)

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

 6. Initiate ART for any child less than 18 months of age who has been given a presumptive clinical diagnosis of HIV infection. (18 v atmuf HIV/AIDS vuPm rsm;awG.vQif ay;oifhonf/)

 What to start recommended first-line ART regimens for infants and (yxr tqifh aq;? &dK;&Sif;aom enf;vrf; jzifh p&ef)

rnfonf regimen ESifh poifh oenf;/

Infants (arG;uif;p uav;rsm; twGuf) 1) rdcif rS PMTCT twGuf ART raomuf ao;vQif (2 NRTI s + NNRTI) 2) rdcif rS PMTCT twGuf ART aomuf jyD;vQif (lopinavir/ritonavir (LPV/r) + 2 NRTIs) 3) aq;aomuf jyD;^rjyD; raocsmvQif (2 NRTI + NNRTI)

rnfonf regimen ESifh poifh oenf;/

Children (uav;rsm; twGuf)

1) touf 12 v rS 24 v txd uav; rsm;wGif rdcif onf PMTCT rS ART aomuf xm;vQif (lopinavir/ritonavir (LPV/r) + 2 NRTIs) 2) touf 12 v rS 24 v txd uav; rsm;wGif rdcif onf PMTCT rS ART raomuf xm;vQif (2 NRTIs + NNRTI) 3) 24v ESifh 3ESpf Mum; qdkvQif (NVP + 2 NRTIs) 3 ESpfatmuf wGif EFV rokH;& 4) 3 ESpf ESifh txuf qdkvQif (NVP/EFV + 2 NRTIs) 5) arG;uif;pInfants or children twGuf (2 NRTIs + NNRTI) rSm Lamivudine (3TC) + zidovudine (AZT) or 3TC + abacavir (ABC) or 3TC + stavudine (d4T)

rnfonf regimen ESifh poifh oenf;/

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

 touf 3 ESpf ESifh txuf tuberculosis (TB) &SdvQif EFV + 2 NRTIs regimen ay;oiHfhonf/  touf 3 ESpf atmuf tuberculosis (TB) &SdvQif NVP + 2 NRTIs regimen ay;oifhonf odkh a triple nucleoside regimen.  uav; rsm;ESifh tysdK? vlysdK azmf 0if t&G,f aoG;tm;enf;vQif(<7.5 g/dl) or severe neutropenia (<0.5/mm3) NVP + 2 NRTIs regimen wGif AZT udka&Smifyg/  12 ESpf ESif txuf B ydk;&dSvQif tenofovir (TDF) + emtricitabine (FTC) or 3TC + NNRTI.

aq;tnTef; (Austrillia)

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) 4mg/kg/dose twice daily (>8 yrs old) Initial once a day for 2 week

Efavirenz (EFV)= (only for the children over 3 years) 10-<15 kg: 200 mg once daily 15-<20 kg: 300 mg once daily 20-<33 kg:350 mg once daily 33-<40 kg: 400 mg once daily Maximum>40kg: 600 mg once daily

Uav;rsm; twGuf vlMuD;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)

Adult FDC tablets can successfully be given to children who urgently need HAART in resource-limited settings (RLS). resourceOBrien DP et al AIDS 2006

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

1 cm

d4T 30 mg 3TC 150 mg NVP 200 mg

GPOvir BW dosage (kg) kg) Q 12 hr 6-8 1/4 tab 1/2 tab, 1/4 9-11 tab 1212-17 1/2 tab 1818-24 3/4 tab > 25 1 tab

d4T+3TC+EFV
stavudine Lamivudine (150 mg) (30 mg) (50mg) (200 mg) efavirenz
1 cm.

BW d4T (30 m (kg) g) Q 12 hr 12121 4 ca 1515p 1 7 1818-

3TC EFV* (150 mg (50, 200 50, ) mg) mg) Q 12 QD hs hr 200 mg tab 250 mg

yxr 6 v wGif Munfh&rnf tcsufrsm;(on ART)

prepration 1-2M 3-4M 4-6M o o o C ounsellingSESf df q ;aEG f) ( po r a G ;jci ; A Vsideeffect (q du sd) R ; K k ; M onitoringefficacy(aq ;\ x d&m f ) a u rI O pportunisticinfection(O I) Im uneR m econstitutionSyndrom IS) e(IR A dherencem onitoring

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

Ttjzpfrsm;aom ARV qdk;usdK;rsm; Symptoms Rash(teDjyif) ARV NVP EFV Timin g 2-4 week 2-4 week 1-4 week 1-2 week 4-8 week Preval ence 2030% 5-10% Substitut ions EFV, PI NVP, PI

Nausea, vomiting (rl;?tef) AZT Night mare, headahce(tdyfrufqdk;ruf?

acgif;udkuf)

5-10% d4T 2030% NVP

EFV

Anemia (aoG;eDOeJ)

AZT

5-10% d4T

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; wGif 3 v 1 cg csdef; yg uav; aeraumif;vQif &uf pdyfpdyf csdef;yg

CD4 change after ARV %

40 699 35 30 CD4 percentage 492 25 395 20 15 16 10 5 5 0 0 8 24 48 72 155 11 13 350

745

759

800 718 700 600 500 CD4 cell count

24 21

25

26 400 300 200 100 0

96

120

144

Week of ART CD4 percentage CD4 cells

Growth change after receive ARV