Start ARV
Diagno
sis
Improve
survival &
quality of
life
Goal of therapy
Cure the
patient of
infection
Not yet achievable
Control the
infection for a
long period of
time
Starting ARV
Restoratio
n of cell
mediated
immunity
11.5-21%:
IRIS
clinical
ARV
deteriorati
toxicities
on
Failure
Antiretrovi
ral therapy
(ART)
Significant
survival's
improvem
ent
Reduction
opportunis
tic
infections
Eligibility of ARV:
- CD4?
- IO? = WHO
category?
Treat IO how
long?
Prepare and
assess adherence
Diagnosis:
- Definitive
- Presumpt
ive
Start ARV:
- Monitor
adverse
reactions
- Monitor IRIS
Monitor:
Growth
Development
Psychosocial
Improve
survival &
quality of
life
12
WHO
guideline
2013
WHO
guideline
2015
ALL
ALL
ALL
0 12 mo
ALL
ALL
ALL
12 24 mo
ALL
ALL
ALL
24 59 mo
CD4 750
cells/mm3 or
25%
ALL
Priority: CD4 750
cells/mm3 or <25%
ALL
Priority: : CD4 750
cells/mm3 or <25%
5 10 yo
CD4 350
cells/mm3
CD4 500
cells/mm3
Priority: CD4 350
cells/mm3
ALL
Priority: CD4 350
cells/mm3
10 19 yo
(adolescents)
CD4 350
cells/mm3
CD4 500
cells/mm3
Priority:CD4 350
ALL
Priority: CD4 350
cells/mm3
Clinical Immunological
Criteria
Criteria
<24 mo
Therapy
Treat all
Treatb
Stage 2
Stage 1
<25% in children
age 24-59 mo
<350 cells/mm3 in
children >5 yo
Dont treat if no
CD4 value
Treat if CD4 < ageadjusted value
What to prepare?
Starting ART is not an emergency
Asses and
address possible
problems in
adherence
Screen for opportunistic
infection
and treat
to reduce risk of immune reconstitution
inflammatory syndrome (IRIS)
Potential disadvantages of
early initiation of ART
(overlapping treatment)
High pill burden
Co-toxicity
Pharmacokinetic drug interactions
Immune reconstitution disease
More difficult to identify drug
causing toxicity
Current opinion in infectious diseases. 2011;24:34-42
NEJM. 2010;362:697-706
When to start?
US CDC
guidelines
WHO
Consolidated
guidelines
2013
Pharmacological
aspects
Dosing and frequency of the
drugs
Tolerability of the regimen
Access and availability of drugs