Guidelines to Antiretroviral Drug Therapy in Kenya: CHAPTER FOUR: GUIDELINES FOR THE USE OF ANTIRETROVIRAL DRUGS IN PAEDIATRIC HIV INFECTION: 4.9 When to change therapy

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Guidelines to Antiretroviral Drug Therapy in Kenya (WHO; 2001; 78 pages)
	FOREWORD
	ACKNOWLEDGMENT
	CHAPTER ONE: INITIATING ANTIRETROVIRAL THERAPY
		1.1 Introduction
		1.2 Guidelines to making a diagnosis of HIV infection
		1.3 Laboratory Diagnosis of HIV infection
		1.4 Goals of therapy
		1.5 When to start therapy
		1.6 Risks and benefits of delayed initiation of therapy and of early therapy in the Asymptomatic HIV-Infected Patient
		1.7 Antiretroviral profile
		1.8 What drug combination to start with?
	CHAPTER TWO: MONITORING AND CHANGING THERAPY
		2.1 Surrogate markers
		2.2 Resistance testing
		2.3 How often should CD4 Cell Count and Viral Load be performed (Frequency)
		2.4 Treatment failure
		2.5 Reasons for non-adherence
		2.6 Considerations for changing a failing regimen
		2.7 Guidelines for changing an antiretroviral regimen for suspected drug failure
		2.8 Potential options for changing therapy*
	CHAPTER THREE: PHARMACOTHERAPEUTICS OF ARVS
		3.1 Characteristics of available antiretroviral drugs
		3.2 Pharmacokinetic properties of Antiretrovirals
	CHAPTER FOUR: GUIDELINES FOR THE USE OF ANTIRETROVIRAL DRUGS IN PAEDIATRIC HIV INFECTION
		4.1 Overview
		4.2 Diagnosis of HIV infection in children
		4.3 When to initiate treatment
		4.4 Initiation of treatment
		4.5 Agents to choose for initial treatment
		4.6 Dosages for paediatric formulations
		4.8 Monitoring
		4.9 When to change therapy
	CHAPTER FIVE: MANAGEMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTED PREGNANT WOMEN AND PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV
		5.1 Overview
		5.2 Factors affecting mother to child transmission
		5.3 Outline antenatal, intrapartum postpartum and postnatal care
		5.4 Antiretroviral Therapy to prevent MTCT
	CHAPTER SIX: SPECIAL CONSIDERATIONS
		6.1 Acute retroviral syndrome (ARVS)
		6.2 ARV drugs and the treatment of Tuberculosis
		6.3 Immune recovery syndrome
	CHAPTER SEVEN: WHEN TO STOP TREATMENT (INTERRUPTIONS)
		7.1 Structured treatment interruptions (STI's)
		7.2 Non structured treatment interruption
	CHAPTER EIGHT: GUIDELINES FOR POST EXPOSURE PROPHYLAXIS
		8.1 Treatment of exposure sites
		8.2 Timing of post - HIV exposure prophylaxis initiation
		8.3 Assessment of exposure risk
		8.4 Post - HIV exposure prophylaxis
		8.5 Recommended HIV serology after exposure
		8.6 Management of health care workers with accidental exposure to HIV infection
		8.7 Management of hospital staff with sharp injury or exposure to blood and body fluids
		8.8 Management of non occupational exposure to HIV infection
		8.9 Management of non-sexual and non occupational Exposures to HIV
	CHAPTER NINE: ACCESS TO DRUGS IN KENYA
	APPENDICES
		I. Drug to drug interactions
		II. Drug to drug interactions (continued)
		III. Drug Interactions Between Antiretrovirals and Other Drugs
		IV. Nucleoside Reverse Transcriptase Inhibitors (NRTIS)
		V. Drug Interactions: Protease Inhibitors
		VI. Drug Interactions: Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors - Cont.
		VII. Drug That Should Not be Used With Antiretrovirals
		VIII. Drugs that should not be used with Protease Inhibitors Antiretrovirals
		IX. HIV-related drugs with overlapping toxicities
		X. Anti-retroviral therapy for preventing MTCT
	BACK COVER

4.9 When to change therapy

Virologic considerations

i) Inadequate virologic response after 8-12 weeks of therapy Le.< 10 fold reduction from baseline levels in children receiving "NRTIs and PI or <5 fold reduction from baseline in children receiving "NRTIs.

ii) Repeated detection of HIV RNA in children who were initially undetectable.

iii) A greater than 3 fold increase in viral copy number in infants <2 years.

iv) A greater than 3 fold increase in viral copy number in infants>2 years.

Immunologic considerations

i) Change in immune classification (e.g. from moderate to severe immune suppression)

ii) For patients with severe immune suppression (CD4 levels <15%), a persistent decline of 5 percentiles or more.

iii) A rapid and substantial decrease in CD4 counts i.e. >30% decline in <6 months.

Clinical considerations

i) Progressive neurodevelopment deterioration.
ii) Growth failure.

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