Transcript When to start Antiretroviral Therapy in Children

Antiretroviral Therapy
in Children With Drug
Resistance Virus
By
Kulkanya Chokephaibulkit, MD
Department of Pediatrics
Faculty of Medicine Siriraj Hospital
Mahidol University
Recommended Drug Regimen to Start
USA (2008)
Preferred
EU (2004)
First choice
WHO (2008)
Preferred Options
 2NRTIs+ LPV/r or ATV/r  2NRTIs+ LPV/r or NFV  AZT/ABC/d4T+3TC+
or
2NRTI + EFV (or NVP
NVP/EFV
2NRTIs+EFV or NVP
in < 3Y)
For infants exposed to
Choices of 2NRTI
SD-NVP consider
 AZT+3TC/FTC
 AZT/d4T/ABC+3TC+
LPV/r
ABC+3TC/FTC
ddI+FTC
TDF+3TC/FTC (>18yo)
THAILAND (2007)
 May use AZT+ABC,
 AZT/d4T+3TC+
NVP / EFV (in > 3yo)
AZT+ddI
AIDSinfo.nih.gov
Sharland M. HIV Med 2004
www.who.int
Children Do Not Response to HAART As Well
As Adults
VL and CD4 At 12 Months After Initiation of HAART
Judd A. CID 2007;45:918-24.
In Usual Practice in UK
By 6 Years of Treatment
N=4306
• Virological failure
38%
• >1 major mutation
27%
• Mutation > 2 drug classes
20%
>>PI with RTV had lower risk of resistance
The UK Collaborative Group on HIV Drug
Resistance, UK CHIC Study Group
Effectiveness of HAART in HIV-Positive Children:
Evaluation at 12 Months in a Routine Program
in Cambodia
Survival of children who started HAART in Takeo and Siem Reap.
Factors associated with
VL>400 after 12 M of HAART
is being orphans
Janssens B. Pediatrics 2008;120:e1134-1140.
Predictors of Long-Term Viral Failure Among Ugandan
Children and Adults Treated With Antiretroviral Therapy
Predictors of Virologic Failure at 12 Months
454 Adults Started on FirstLine Therapy
222 Children and
Adolescents Started on
First-Line Therapy
Multivariate Analysis
Multivariate Analysis
OR (95% CI)
P
OR (95% CI)
P
1.48 (0.77to 2.83)
0.24
2.44 (1.20 to 4.93)
0.01
0.93 (0.35 to 2.45)
1.19 (0.041 to 3.43)
0.88
0.75
2.68 (0.71 to 10.2)
1.04 (0.16 to 6.72)
0.15
0.96
d4T-3TC-NVP vs. ZDV3TC-EFV
2.59 (1.20 to 5.59)
0.02
2.46 (1.23 to 4.90)
0.01
Baseline CD4 <5% or
<100 cell/mm3 (adults)
1.34 (0.74 to 2.40)
0.33
2.69 (1.28 to 5.63)
0.009
Male gender
WHO stage
-Stage III vs. stage I-II
-Stage IV vs. stage I-II
Kamya MR. JAIDS 2007;46:187-93.
Clinical Criteria
for Treatment Failure
• US and Thai
– Progressive neuroldevelopmental deterioration
– Growth failure
– Severe / recurrent infection / illness
• WHO
– New stage 4 condition (very same to AIDS)
– May consider in new stage 3 condition
Immunologic Criteria for
Treatment Failure
• US
– For severe immunologic stage, CD4 response <5% (or < 50
cells) after 1 yr of Rx
– CD4 decline >5% or to less than baseline
• Thai
– Change in immunologic classification
– In those with CD4 <15%, persistent decline >5%
– Rapid decline (30% in 6 mo)
• WHO
– CD4 decline to <15% in 1-3 yo., <10% in 3-5 yo.,
<100 cells in < 5 yo.
Failure Rate of NVP-Based VS
EFV-Based regimens in Thai children
(Siriraj Hospital): Median F/U = 3 yr
Naive
- No. of failure needed to
switch from NNRTI
- Median duration of Rx
Experience
NVP
EFV
NVP
EFV
1/38
2/34
9/23
10/44
(39%)
(22.7%)
24
18
(2.6%) (5.8%)
24
24
before switching (mo.)
All were switched to boosted PI or double boosted PI
Virologic Criteria for Treatment Failure
• US
– Incomplete response to RX (VL decline < 1 log after 3 mo of
Rx (>6 mo in experienced cases) or VL still > 400 after 6 mo
– Viral rebound (Increase >0.5log (3-fold) in >2 yo or
>0.7 log (5-fold) in <2 yo)
• Thai
– Same as US
• WHO
– No criteria. However, if CD4 and clinical criteria are
conflicting, then use HIV-RNA >100,00 copies/mL as
consideration to change treatment
Some Facts
• Some patients who were on HAART may
maintain clinical and immunological benefit
up to 3 years despite detectable virus
>> Patients who have persistent
improvement of CD4 despite persistent
viremia, should be considered to continue
ART. However, if appropriate regimen is
available, it is preferred to change before
more resistance developed
Treatment Failure Defined by
Immunologic Markers Alone May
Result in Unnecessary Regimen
Change in Resource-Limited Settings
• In 54 adherent, clinically stable patients with
immunologic failure (category 3)
– HIV-1 RNA >400 copies in 30 (56%) cases
• Median HIV-1 RNA: 93,686 copies/mL
(range: 2611-694,993)
– HIV-1 RNA <400 copies in 24 (44%) cases
Basenero A, Castelnuovo B, Birabwa E, et al. 4th IAS, July 22-25, 2007; Sydney, Australia. Abstract WEAB102.
Number of Children Taking ART Under NHSO Was
7,908 (September 2008)
จำแนกตำมช่วงอำยุ
No.
คน
รับยา
1000
900
800
700
600
500
400
300
200
100
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
รวม
15
ปี
Age in Yr
www.nhso.go.th
Result of HIV-RNA Tests (N= 5,925 specimens)
(September 2008)
VL=>2,000;
1,503; 25%
VL<2,000;
4,422; 75%
VL<2,000
VL=>2,000
www.nhso.go.th
Resistance is probably
the cause of failure if the
patient takes medicine
Fact:
Imperfect adherence hasten the
time to failure
Resistance Development While on
2NRTI+NNRTI Regimens
Very early failure:
3TC-R: M184V
Early failure:
3TC-R: M184V
NNRTI-R: e.g.K103N, Y181C/I, Y188L, G190A/S
Other NRTI-R: minimal or none
Late failure:
3TC-R: M184V
NNRTI-R: e.g.K103N, Y181C/I, Y188L, G190A/S
TAMs: M41L, D67N, K70R, L210W, T215Y, K219Q/E
Drug Resistance Mutations in Adults Who
Failed FDC of d4T/3TC/NVP
Sungkanuparph S. CID 2007;44:447-52.
Predictors of Long-Term Viral Failure Among Ugandan
Children and Adults Treated With Antiretroviral Therapy
Genotype Mutations CD4 Count
Patient No.
(Age in Years)
1 (27)
Regimen
At 6-12 Months
NVP, 3TC, d4T
M184V, K103N
2 (31)
NVP, 3TC, d4T
M184V, K103N, T215Y
3 (26)
NVP, 3TC, d4T
M184V, K103N, G190A
4 (32)
NVP, 3TC, d4T
V751, M184V, Y181C, T69N,
V751, T215Y
5 (41)
NVP, 3TC, d4T
M184V, K103N
6 (13)
NVP, 3TC, d4T
M184V, L210D, G190A
7 (16)
NVP, 3TC, d4T
M184V, K103N
8 (10)
EFV, 3TC, d4T
T69S, M184V, Y188L
Kamya MR. JAIDS 2007;46:187-93..
Class-Sparing Regimens for Initial
Treatment of HIV-1 Infection
EFV + 2NRTI has
lower chance of
virologic failure than
LPV/r + 2NRTI.
P <0.003
@wk 96
+2NRTI
+2NRTI
EFV+LPV/r was equal
to EFV+2NRTI, but
more likely
associated with drug
resistance.
Riddler SA. NEJM 2008;358:2095—2106.
Emergence of
Drug
Resistance
After Receipt of
First-Line
HAART
A Systematic Review
of Clinical Trials at 48
wks by ITT
Virologic Failure @ 48 wk
NNRTI = 4.9% (3.9-6.1%)
bPI = 5.3% (4.4-6.4%)
Gupta R. CID 2008;47:712-22.
Prevalence of NRTI Resistance Among 95 HIV-infected
Children Who Had Received Dual NRTI For > 6 Months
NAMs, 60% had <4 NAMs, and 40% had NAMs.
Lolekha R. CID 2005;40:309-12.
Interpretation of Genotypic Resistance
• NRTIs:
–
–
–
–
–
–
–
–
–
–
TAM I: M41L, L210W, T215Y
TAM II: D67N, K70R, K219Q, K219E
Any TAM: resist to AZT
TAM I pathway: More resistance; TAM II: still can use ddI, TDF
M41L + T215F/Y: resist d4T
2-3 TAMS may be able to use ddI, TDF, ABC
>3 TAMs: resist all NRTI
M41L, L210W, T215Y pathway is more resistant than D67N, K70R,
K219Q/E
69 insertion+ T215Y+ 2 of M41L, A62V, K70R, L210W : resist to all
NRTI
Q151M complex: Q151M+F77L+(A62V, V75I, F116Y): resist to all
NRTI except TDF
L74V, K65R: resist to ABC and ddI
K65R: resist to TDF, but still susceptible to AZT
Drug Options for Salvage
Regimens
• NRTI
– AZT if no bad TAMs
– ddI, TDF, ABC if < 4 TAMs, and no K65R
– (TDF should not be used for <18 yo, and ABC is
expensive)
– 3TC may still use with M184V to reduce fitness
• NNRTI: once resist, no option left
• PI:
–
–
–
–
LPV/r is excellent esp. for PI naïve
ATV/r is expensive, use with dyslipidemia
SQV is expensive, and only pill available
IDV/r is less potent and renal toxic
Interpretation of Genotypic Resistance
• NNRT: Any single mutation cause high level
resistance
• PI: need more than 3-4 mutations to confer
resistance
– 2 UPAM (universal PI-asso mutation) at 82, 84,
and 90 position will resist to RTV, IDV, SQV, APV
Options for a Second-Line Regimen For Adults
Who Failed FDC of d4T/3TC/NVP
NRTI resistance pattern
Options for the second-line ART regimen
PI-based regimen
Backbone NRTIs in settings
without NRTI limitation
(Boosted) PI
AZT plus ddI or TDF
M184V plus TAMs
Boosted PI
ddI plus ABC or TDF
M184 plus K65R
Boosted PI
AZT plus ABC or d4T plus
ABC
M184V plus Q151M
(Double) boosted PI
TDF plus?
Q151M alone
(Double) boosted PI
TDF plus?
K65R alone
(Boosted) PI
3TC plus either AZT, ABC, or
d4T
No NRTI resistance
(Boosted) PI
3TC plus either TDF, ddI, AZT,
ABC, or d4T
M184V alone
Sungkanuparph S. CID 2007;44:447-52.
What Regimen to Change To (US)
Initial Regimen
Recommended Change
2 NRTIs+NNRTI
- 2 NRTIs (based on resistance testing) plus PI
2 NRTIs+PI
- 2 NRTIs (based on resistance testing) plus NNRTI
- 2 NRTIs (based on resistance testing) plus alternative PI (with
low-dose ritonavir boosting If possible, based on resistance
testing)
-NRTI(s) (based on resistance testing) plus NNRTI plus
alternative PI (with low-dose ritonavir boosting if possible,
based on resistnace testing)
3 NRTIs
(recommended only
in special
circumstances)
- 2 NRTIs (based on resistance testing) plus NNRTI or PI
- NRTI(s) (based on resistance testing) plus NNRTI plus PI
Failed regimens
including NRTI,
NNRTI, PI
(recommended only
in special
circumstances)
- >1 NRTI (based on resistance testing) plus a newer PI (with
low-dose ritonavir, based on resistance testing)
Guideline for the Use of Antiretroviral Agents in Pediatric HIV Infection Oct26, 2006
RECOMMENDED SECOND-LINE REGIMENS IN
INFANTS AND CHILDREN IN THE EVENT OF
TREATMENT FAILURE OF FIRST-LINE REGIMENS
First-line regimen at failure
Preferred second-line regimen
(A(II))
RTI components
(NRTI/NNRTI)
PI component
LPV/r
2 NRTI + 1 NNRTI
AZT- or d4T- containing
ddI + ABC
Or
plus
ABC + containing
Triple NRTI
SQV/r
ddI + AZT
Or
ddI + EFV or NVP
NFV
WHO Guideline 2006
Nelfinavir
Contamination with
a carcinogen, ethyl
methane sulfonate
(EMS) during the
production.
Do Not Use
Problems of Drugs for Salvage
Regimens for Children in Thailand
• ddI available in giant generic tablet to dissolve in
water, unfriendly taste. ddI-EC is not available by
NHSO, and not for young children.
• ABC is expensive and not available by NHSO
• TDF is available but can use only in adolescents
and adults
• LPV/r available only in adult generic tablet
(200/50), children need to cut the pill
• IDV is available, but the TDM is not feasible in
routine
• SQV is expensive and not available by NHSO
• ATV is limited available, and only in adult tablet
formulation
Lopinavir/ritonavir
(Cap133/33, Tab 200/50, Tab 100/25)
Abbott
133/33 mg
Matrix
200/50 mg
• Heat stable tablet is
easier
• Recommended dose
using 200/50 mg tab:
– 15-25 kg
1 tab
– 25-35 kg
– > 35 kg
1.5 tab
2 tab
Study in 33 children (14 used 1.5 tab) at Siriraj, QSNICH, HIVNAT
Mean Ctrough (SD) = 8.2 (5.7) using Abbott
= 8.2 (5.4) mg/L using Matrix
Recommendation of Salvage Regimen
in Thai Children
Failing Regimens
AZT/d4T+3TC
Salvage Regimens
Preferred
+EFV/NVP
- ddI+3TC or ddI+ABC Plus LPV/r
- GPOvir S
Use TDF(+AZT/3TC) if Tanner stage 4 or > 18 yo
- GPOvir Z
Alternative if > 3 (bad) TAMs esp. with high VL
-Double boosted PI (e.g. LPV/r+SQV,
LPV/r+IDV) +/-3TC
Need good adherence, and close monitoring
* TAM mutation = 41L, 215Y, 210W, 67N, 70R, 219Q/E
Salvage Regimen for The Patients
Who Fail dual NRTIs Regimens
•
If < 3 TAMs or good TAMs:
– New 2NRTI + boosted PI
•
If > 3 TAMs (esp” bad TAMs 41L, 210W, 215Y) :
– NNRTI + boosted PI + 1-2NRTI
•
Careful if to salvage with NRTIs + NNRTI
•
Always check genotype if to continue NRTI
Advantages vs Drawbacks of Each PI
Advantages
LPV/r
SQV/r
Highly effective
High resistance
threshold
Liquid formulation available
Good efficacy
No dyslipidemia
IDV/r
Effective
Small and Less pill
ATV/r
Highly effective
No dyslipidemia
Drawbacks
Need refrigerator
Big size pill
Expensive
GI side effects, and dyslipidemia
Dose only for >25 kg
Big size, and many pills
Expensive
GI side effects
Kidney toxicity
Need hydration
Need blood level monitoring
Expensive
May cause hyperbilirubinemia
Use only for > 6 year-old
Efficacy of 2NRTI+lopinavir/ritonavir
In 21 PI-naïve Children Who Failed 2NRTI+NNRTI
100
100
90
80
70
92
86
71
60
Viral load <400
Viral load <50
50
40
30
20
10
0
6 months
12 months
Delaugerre, et al. J Acquir Immune Defic Syndr 2004;37 :1269-1275.
Factors Influencing Virologic Response (VL<400 copies/mL) In Children
Receiving LPV/r Salvage Regimens ( Response in 56/67; 66%)
a
Beginning of HAART protocol with LPV and other new drugs.
Resino S. JAC2004;54:921-31.
FDA Approved ATV In Children March 2008
• ATV capsule can be used from >6 yo.
• It should be used with RTV
• It should not be used in <3 mo.
• Safety: Cough 21%
Jaundice 13%
Fever 19%
Diarrhea 8%
Headache 7%
Running nose 6%
Increase bilirubin 49%
• Efficacy at 24 wk, VL <50
Rx-naïve : 59%
Rx-exp : 24%
Increase CD4 : 171 cell/mm3
http://www.aidsmap.com/en/news/80F577BE-9DFE-4796-B4A7-BC9E0CB33149.asp
Indinavir Plasma Levels at Different Dosage
IDV can be used safely at 220-300 mg/M2 plus RTV 100 mg
100
Dosage
IDV
IDV concentration, mg/L
RTV
Children
220-300 mg/M2
100mg
Adults
600mg
Adults
400mg
Children
400 mg/M2
400mg/M2 100mg
100mg
125 mg/m2
10
Level
associate
with
toxicity
1
Minimum
target
trough
.1
Plipat N, et al. PIDJ
2007;26:86-8
Cressey TR, et al. JAC
2005;55:1041-4.,
Bergshoeff AS.
AAC 2004;48:
1904-7.
0.01
A
B
C
D
E
Cmax
Cmin
National Access Program to ART (NHSO)
(September 2008)
C
1%
E
3%
D 9%
B 2%
A
85%
A
A= AZT/d4T+3TC+NVP/EFV
C= ddI/TDF+3TC+IDV/r or NNRTI
D = others
B
C
D
E
B= AZT/d4T+3TC+IDV/r intolerance to A
D= 2NRTI + LPV/r
www.nhso.go.th
At least half of the infants
exposed to perinatal singledose NVP developed NVP
resistance.
Infants may need SECOND-LINE
regimen from the start!
Check genotype for NVP-R to all infants exposed to SD-NVP
Frequency of Development of NVP
Resistance
in
Infants
Rate (%)
100
90
NVP-R reduced by
eliminate maternal
NVP and use of
neonatal NVP+AZT
87
80
74
70
60
57
50
Mom - Baby
40
A1= NVP
-
NVP
A2= NVP
-
NVP/AZT
20
B1= NO
-
NVP
10
B2= NO
-
NVP/AZT
30
27
0
NVP- R
Eshleman SH. JID 2006;193:479-81.
VL <400 at 6 mo Rx
Response to NVP-based HAART After
Exposure to Peripartum SD-NVP (MASHI)
120
100
100
88 92
90
80
60
58
NVP (N=112)
Pla (N=106)
40
20
P<0.001
P= 0.39
<6 mo
> 6mo
23
0
N = 60
N = 158
Infants
Mean age of Rx
initiation = 8 mo.
Time from SD-NVP/Pla
Lockman S. NEJM 2007;356;11:135-47.
We Should Test for Drug Resistance in
All Infants Exposed to SD-NVP
• More incidence of NVP-R in adults recently
• High rate of NVP-R in infected infants (50%) after
single dose perinatal exposure
What if Genotyping is not available
• May try NVP regimen with close VL
monitoring
• Infants who have a very rapid disease
progression should not try NVP regimen,
but should get LPV/r
A Cases Scenario
• A 3 week old infant, healthy, came for F/U
• The mother received AZT from 34 week and
SD-NVP at labour
• The infant received AZT+3TC+SD-NVP
• The PCR at birth was positive
• Need to start HAART ASAP, and check if there is NVP-R
• Don’t forget to give AZT+3TC plus NVP (SD or 2 wks) in
high risk cases (late Rx, poor compliance)
Antiretroviral Drugs for Neonates Exposed to HIV
Drugs
• Syr. AZT
• SD-NVP
• NVP
• Syr 3TC
Dose
2 mg/kg Q 6 hr
or 4 mg/kg Q 12 hr
2 mg/kg @ 48-72 hr-old
2 mg/kg Q 24 hr x 7 d
then 4 mg/kg Q24 hr x 7 d
2 mg/kg Q 12 hr
Duration
1-6 wks
1-6 wks
once (or twice)
total 2 wk
1-4 wk
Thai-MOPH
SD-NVP 2 mg/kg @ birth or 48-72 hr. + Syr. AZT 2 mg/kg Q 6 hr
x1 wk if maternal AZT >4 wks OR x 6 wks if maternal AZT <4 wks
LPV/r in Infants Younger than 6 Month
• Slightly higher clearance than older children
• At 24 weeks, 53% had VL < 400 cp/mL
• Poor adherence is the problem of virologic
failure
• Suggested dose in <Chadwick
6 mo EG.
= 300/75
mg/M2 (vs
AIDS 2008; 11;22(2):249-55
230/57.5 mg/m@ in > 6 mo)
• PACTG 1030: After 24 wks of LPV/r-HAART
initiate before 6 mo, 70% had VL<50 cp/mL
Persaud D. JID 2007;195:1402-10
LPV/r-Based Versus NVP-Based
HAART For Infants
LPV/r
• Advantages:
– Highly effective
– Better immunologic
response
– Liquid formulation available
– No pre-existing resistance
– High resistance barrier
• Disadvantages:
–
–
–
–
Expensive
Not good taste
Should be refrigerated
Less experience in < 6 mo.
(not approved)
NVP
• Advantages:
– Cheap, affordable in all
settings
– Better taste
– Liquid formulation available
– May be less effective
– FDC available
• Disadvantages:
– May have pre-existing
resistance esp. from
perinatal NVP use
– Low resistance barrier
– Potential A/E in 15-20%
(hepatitis, rash)
Management of Some Adverse
Events From ARV
• Switch ARV:
– Anemia -> change AZT
– Lipodystrophy -> change d4T
– Rash, hepatitis-> change NVP (sometimes
EFV)
• Dyslipidemia: start intervention when
• Cholesterol > 200 mg%
• LDL > 130 mg%
• Triglyceride > 200 mg%
– Start with diet control, exercise
– If not improve, consider switch to ATV (now
approve from 5 yo.)
Prevalence of Dyslipidemia from the Data
Collection on Adverse Events of Anti-HIV
Drugs (D:A:D)
Fontas E. JID 2004;189:1056-74.
Rash from
Nevirapine
• Found in 15-20% mostly within
2-4 wks (up to 12 wks)
• may associated with hepatitis
• Can’t be prevented by steroid
• Rx: stop NVP, antihistamine
(+steroid)
Lipodystrophy Associated with Stavudine
Mostly found in older children getting into puberty
1/3 improved after stopping d4T and with growth spurt
Risk of Extensive Virological Failure to The Three
Antiretroviral Drug Classes An Observational cohort study
Cumulative risk of
extensive triple-class
virological failure
Cumulative
risk of
virological
failure of for
individual
drug classes
according to
years from
start of that
class
PI/r=ritonavir-boosted protease inhibitor.
Phillips AN. The Lancet 2007;370:1923-8.
Lower Risk of AIDS If Stay On Failing Regimens
French cohort 2000-2005 in patients
with CD4 <200 for > 6 months
New AIDS
event
(per pt-yr.)
Stay on Falling
Regimen
(> 1 drug)
VL >500
Interrupt Rx
VL >500
On HAART
VL <50
N = 8783
14.5
N = 2399
18.5
N =4351
4.5
- New AIDS event associated with CD4 <50, VL >30,000
- Interrupt Rx had highest risk of AIDS
Kousignian I. CID 2007;46:296-304
What need to investigate next
in children?
• Double boosted vs single boosted PI in
PI-naïve patients
– From initiation of salvage
– After successful viral suppression
• What to use after first-line PI resistance
– New PI: Darunavir
– New class: Integrase inhibitor, receptor
antagonist
Second-line regimen in children
Retrospective cohort: 8 centers from Thailand
241 children failed NNRTI-based regimen
Single-boosted
(n=104)
Double boosted PI
(n=137)
8.9(6.1-11.1)
9.4 (7.6-11.2)
17 (7-24)
6 (2-12)
Plasma HIV RNA
4.5 (3.9-5.1)
4.9 (4.5-5.4)
Multi NRTI resistance
11/89 (12.4)
69/114 (60.5)
HIV RNA <400 copies ml
49/59 (83.1)
42/50 (84.0)
7 (2-12)
10 (6-15)
Age
CD4%
CD4% gain (n=147)
Puthanakit and Ananworanich, et al.-in preparation
Changes in Risk of Death
After HIV Seroconversion Compared
With Mortality in the General Population
45
Excess Mortality (/1000 person year)
40.8
40
35
31.4
30
25
20
15
11.9
10
9.5
8.5
6.1
5
0
Pre-1996
19961997
19981999
20002001
20022003
20042006
Bhaskaran K. JAMA 2008;300:51-9.
Adjusted Life Expectancy On CART
In High-Income Countries
An analysis of 14 cohort studies by year of F/U and baseline CD4
1996-9 2000-2
At exact age
2003-5 1996-2005
CD4 <100
CD4100-199
CD4 >200
36.1
41.2
49.4
43.1
32.4
42.0
50.4
25.0
30.1
37.3
31.7
27.0
30.4
37.2
75.5%
79.5%
85.7%
81.1%
59.8%
80.6%
89.9%
20 years
At exact age
35 years
% surviving
from 20- 44 yr
The average number of years remaining to be lived at age 20 years
was about 2/3 of that in the general population in these countries.
The Lancet 2008;372:293-9.
Age Group Distribution of HIV-Infected
Children at Siriraj Hospital (Feb 08)
120
104
Number of Patients
100
85
80
60
40
26
19
20
0
Below 5 Yrs
5-9 Yrs
10-14 Yrs
Age Group
15-18 Yrs
Next Challenging Issues For The
Grown-Up HIV-Infected Children
• Disclosure: children need to know their
diagnosis and get positive attitude before
becoming adolescent
• Lifelong adherence
• Being a teenager
– Sex issues
– Peer’s acceptance
– High risk behaviors
• Future education and career
• Making own family
Care
Givers &
Family
Care
Provider
Team
Treatment
• Supportive
• Specific
• Palliative
Y
O
U