Session 10: ART Initiation

Starting Children on ART

In this session, we will discuss the benefits of Antiretroviral therapy, how to assess client readiness for ART in various populations, the appropriate ART regimen and dosage, and effective adherence support interventions and strategies for supporting adherence to ART.

Learning Objectives

By the end of this session, you will be able to:

• Explain the eligibility criteria for starting ART in children under 10 years old.
• Describe the ART regimen and dosage for children under 10 years old.

Learning Activities

• Starting Children on ART (5 min)

  Watch this video for an introduction to ART.
• Daniel (5 min)
  

  Daniel is a 9-month-boy referred by the OI clinic with a history of FTT since 4 months of age. His mother tested HIV positive at antenatal care. She received ART and her child given NVP at birth. She has been breastfeeding for 3 months and still breastfeeding at time of referral and DBS positive at local clinic.

  Daniel has been treated for skin rashes on and off and currently experiencing irritability, rapid breathing, poor feeding, and fever. NVD at term, birth weight 3 kg, apgars 9 and 10. He was admitted in hospital with pneumonia at 4 months.

  1What additional information is necessary for accurate WHO staging of this child? Tap the compare feedback button to compare your answer with an expert's.

  Clear Compare Answer

  • Developmental milestones
  • Current weight and the degree of failure to thrive
  • Current diagnosis following the current clinical presentation
  • Any history of TB
  • Clinical examination findings e.g. hepatosplenomegaly, oral thrush

  During your examination, your findings are:

  • A wasted child weighing 3.6 kg.
  • Pale
  • Oral thrush
  • No respiratory distress
  • 3 cm hepatomegaly

  2In what WHO clinical stage is Daniel?

  1. Stage 1
  2. Stage 2
  3. Stage 3
  4. Stage 4

  Clear Feedback

  C and D are correct. He is probably in paediatric WHO stage 3 or 4 depending on the severity of the failure to thrive, which you can further assess by looking at the Child Health Card.

  3What is your plan? TTap the compare feedback buttonto compare your answer with an expert's .

  Clear Compare Answer

  • Commence him on cotrimoxazole prophylaxis, treat the oral thrush with a 50 mg stat dose of fluconazole and screen him for TB.
  • Initiate the discussion about commencing ART and ask the mother to bring her husband and other siblings for HIV testing.
  • Manage his current clinical problems including the irritability, rapid breathing, poor feeding, and fever.
  • Do the baseline bloods related to his current diagnosis and also in preparation for ART initiation.

  One week later after your review, you have ruled out TB, made sure he no longer has oral thrush and has not reacted to cotrimoxazole. You counsel the parents and ask them to come back in a week. Two weeks later, you reassess Daniel, get his baseline blood results back and decide to commence him on ART.

  4What ART regimen would you start this 9-month-old baby on?

  1. AZT+3TC+NVP
  2. AZT+3TC+EFV
  3. ABC+3TC+lopinavir / r
  4. TDF+3TC+lopinavir / r

  Clear Feedback

  C is correct. Children below 3 years are commenced on a PI based first line regimen.

  5What important laboratory test would you do to determine ART regimen for Daniel?

  1. FBC
  2. Serum Creatinine
  3. ESR
  4. Blood Sugar

  Clear Feedback

  A is correct. It is essential to exclude anaemia before starting baby on an AZT based regimen.

• Knowledge Check (5 min)

  1What is the definition of a child? Select all that apply.

  1. Anyone 12-18 years
  2. Anyone still staying with his/her parents/caregivers
  3. Anyone going to school
  4. Infants
  5. Anyone who is 1-8 years
  6. Anyone below 18 years of age

  Clear Feedback

  A, D, E, and F are correct. Anyone below 18 years is a child regardless of their living situation, or whether they attend school.

  2Select all statements that are true regarding CD4 cell counts or percentages in a child. Select all that apply.

  1. They are indicator of the status of the immune system
  2. Can fall abruptly in infants with HIV infection
  3. Are useful in determining ART eligibility in children
  4. CD4 counts may vary in number by day and night
  5. Are high in number when a child has opportunistic infections

  Clear Feedback

  A, B, and D are correct. C is incorrect because we now treat all. E is incorrect because they are low if the child has an OI.

  3The following HIV positive children need CD4 screening before initiating ART.

  1. DNA-PCR positive infants at birth
  2. Confirmed HIV infected children less than 2 years
  3. DNA-PCR positive infants at 6 weeks who has never breastfed
  4. Rapid test antibody HIV positive 13-year old boy
  5. None of the above

  Clear Feedback

  E is correct.

  4Chido, an HIV exposed infant presents in your clinic for her 10-week review. Her results of the HIV DNA PCR test conducted at 6 weeks are positive. Her mother is on ART, taking TDF/3TC/EFV. What ART regimen would you start this baby on?

  1. AZT+3TC+NVP
  2. AZT+3TC+EFV
  3. ABC+3TC+lopinavir/ r
  4. TDF+3TC+lopinavir/ r
  5. TDF+3TC+EFV

  Clear Feedback

  C is correct.

• Key Points (5 min)
  • HIV progresses rapidly in infants and young children, so all infants and children should be tested at their first contact with the health system, ideally at 6 weeks of age.
  • All children confirmed to be HIV infected are eligible for ART regardless of their CD4 count/ percentage or WHO clinical stage and they should be initiated on ART at the earliest possible time after diagnosis (preferably on the same day of diagnosis).
  • Children grow and gain weight therefore they should be weighed at each visit because dosage of ARVs is determined by weight.
  • After weighing the child, consult the paediatric dosing chart to determine the correct dose of ART to give. It is not possible/necessary to memorise paediatric ART regimens!