Paediatric HIV infection in developing countries

1
Paediatric HIV infection in developing countries

• Early failure and resistance

EACS - 7th Advanced HIV Course Dr David GERMANAUD
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HIV in children 3 challenges
Eradicate the disease Stop MTC transmission
Occidental MTCT under HAART lt 0,5
Generalised optimal PMTCT HAART for all
infected mother
Treat massively Diagnose the disease
2 adults ? 1 child We are still far from it!
Screening policy in children
Secure the futur Reduce failure
3
7yrs
8yrs
9yrs
6yrs
clinical deterioration
ddI 3TC NVP
ddI 3TC NFV
ddI 3TC AZT
AZT 3TC NFV
vomiting
ABC AZT 3TC NFV
Mohamed
R
20kg CIV I IV (10CD4)
14kg CIII I IV (18CD4)
18.5kg CII I IV (5CD4)
18kg CIII I IV (2CD4)
I IV (75CD4)
16000cp
underdosage
4
5yrs
6yrs
7yrs
4yrs
d4T 3TC NVP
d4T 3TC NFV

d4T/AZT 3TC IDV
Siriba
allergic rash
CIII (RCSPc) I II (400CD4) 5000cp
CIII (RCSPc) I II (450CD4)
CIII (RCSPc) I II (370CD4) 330000cp
CII I IV (200CD4)
0TAMs S AZT 3TC R NVP, EFV
misdosage, difficult in children
5
Early virological failure (M6) in children
1/2
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Early resistance (M6) in children
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What to do with M6 failure?
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1
Fatoumata
20 months 6.5kg (lt-3SD) 76cm (lt-2SD) 44.5cm
(-1SD), C IV unexplained cachexia I IV
310CD4 (16) 340000cp
26 months 9.5kg (lt-1SD) 82cm (-1SD) 46cm
(-1SD) C I I II 990CD4 (29)
AZT 3TC NVP
Hawa
31 months 11kg (-1SD) 88cm (med) 47cm (med) C
I I III 770CD4 (23) 12000cp
37 months 12kg 95cm 48cm C I I I 1600CD4
(44)
AZT 3TC NVP
9
lt 0,5Log10
gt 0,5Log10
indetect.
?VL
N, in which 3TC
NN
IP
Thepautic class.
R probability
Adjé-Touré 2007
10
Is treatment still fitting?
3
How to improve compliance?
2
11
13kg
12mL x2 AZT, 6mL x2 3TC, 10mL x2 NVP  12 tbl
spoon /d 1 months 8 bottles of 240mL 2L
Invested father, regular follow up, several check
up Chronic failure for this 6 yrs old boy
?
13 years old boy 1th line chronic failure Poorly
invested parents
 Stigmatizing treatment 
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Robustness capacity to support the disturbances
4
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To sum up

• From 1/3 to 1/2 children face failure at M6 of
  2N1NN first line.
• Resistance is the rule and demands treatment
  adaptation.
• Early adaptation does not spoil futur but try and
  limit R accumulation.
• Adaptation policies need local resistance
  epidemiological data that has to be generated.
• When available, genotyping will firt and long
  concerned chronic failure and 3rd to 4th lines.