{"id":7822,"date":"2010-02-07T00:10:17","date_gmt":"2010-02-07T00:10:17","guid":{"rendered":"http:\/\/moomango.co.uk\/htb\/?p=7822"},"modified":"2013-08-06T07:41:26","modified_gmt":"2013-08-06T07:41:26","slug":"updated-paediatric-hiv-treatment-guidelines-penta-2009","status":"publish","type":"post","link":"https:\/\/i-base.info\/htb\/7822","title":{"rendered":"Updated paediatric HIV treatment guidelines (PENTA, 2009)"},"content":{"rendered":"

Polly Clayden, HIV\u00a0i-Base<\/strong><\/p>\n

The updated PENTA guidelines were published in the November 2009 edition of HIV Medicine. These guidelines offer practical recommendations for treating\u00a0children with HIV in Europe.<\/strong><\/p>\n

The main changes since the 2004 guidelines are:<\/p>\n

When to start?<\/h2>\n

Universal treatment is recommended as soon as possible after diagnosis for all
\ninfants less than 12 months of age. The guidelines stress particular urgency for infants infected despite prevention of mother to child transmission\u00a0(PMTCT).<\/p>\n

For children 12 months or older, HAART should be started in all symptomatic cases (CDC stage B or C, WHO stage 3 or 4). Children 12 months or older with\u00a0no or minor symptoms (CDC stage A or N or WHO stage 1 or 2) treatment should be started when CD4 count or percentage falls below the following thresholds:<\/p>\n

1 to <3 years\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 CD4<25% or 1000 cells\/mm3<\/sup><\/p>\n

3 to <5years\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 CD4<20% or <500 cells\/mm3<\/sup><\/p>\n

Above 5 years\u00a0\u00a0\u00a0\u00a0 CD4 count <350 cells\/mm3<\/sup><\/p>\n

These treatment thresholds differ significantly from the 2004 guidelines, see Table 1 for comparison of PENTA guidelines 2004 and 2009. Some\u00a0recommendations also differ from the WHO and US treatment thresholds, see Table 2 comparison of PENTA, WHO and US treatment thresholds.<\/p>\n

In children aged more than 12 months with no or minor symptoms and CD4 counts or percentages above these thresholds, HAART should be considered if the\u00a0viral load exceeds 100,000 copies\/mL.<\/p>\n

What to start with? <\/strong><\/h2>\n

The guidelines recommend a regimen of two NRTIs and either an NNRTI\u00a0or a boosted PI for ARV-naive children with no evidence of resistance. They note that a PI may be preferred in children with anticipated poor adherence.<\/p>\n

Abacavir and 3TC are recommended for children who are HLA-B*5701 negative and AZT and 3TC for those who are HLA-B*5701 positive.<\/p>\n

Nevirapine is recommended for children <3 years and efavirenz for older children.<\/p>\n

Lopinavir\/ritonavir is recommended for young children. For older children alternative boosted PIs may be used, including fosamprenavir\/r and duranavir\/r\u00a0which are licensed for children from 6 years, atazanavir\/r (which is licensed in the US for children from 6 years but not in Europe) and saquinavir\/r\u00a0(which is not licensed for children but may be suitable for adolescents.<\/p>\n

Table 1: Comparison of PENTA guidelines 2004 and 2009<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
<\/td>\nPENTA 2009<\/td>\nPENTA 2009<\/td>\n<\/tr>\n
<\/td>\n0-11 months<\/td>\n0-11 months<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat all<\/td>\nTreat CDC stage B or C<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\n–<\/td>\nTreat <35%<\/td>\n<\/tr>\n
Virological<\/td>\n–<\/td>\nConsider >1,000,000 copies\/mL<\/td>\n<\/tr>\n
<\/td>\n12-35 months<\/td>\n12-47 months<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3or4<\/td>\nTreat CDC stage C<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\nTreat <25% or <1000
\ncells\/mm3<\/td>\n		Treat <20%<\/td>\n<\/tr>\n
Virological<\/td>\nConsider >100,000 copies\/mL<\/td>\nConsider >250,000 copies\/mL<\/td>\n<\/tr>\n
<\/td>\n36-59 months<\/td>\n4-12 years<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3or4<\/td>\nTreat CDC
\nstage C<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\nTreat <20% or <500 cells\/mm3<\/td>\nTreat <15%<\/td>\n<\/tr>\n
Virological<\/td>\nConsider >100,000 copies\/mL<\/td>\nConsider >250,000 copies\/mL<\/td>\n<\/tr>\n
<\/td>\n5 years +<\/td>\n13-17
\nyears<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3or 4<\/td>\nTreat CDC stage C<\/td>\n<\/tr>\n
Immunological
\n(CD4%\/count)<\/td>\n		Treat <350cells\/mm3<\/td>\nTreat <200 cells\/mm3<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Table 2: Comparison of current PENTA, WHO and US treatment thresholds<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
<\/td>\nPENTA 2009<\/td>\nUS 2008<\/td>\nWHO 2008<\/td>\n<\/tr>\n
0-11 months<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat all<\/td>\nTreat all<\/td>\nTreat all<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\n–<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n
Virological<\/td>\n–<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n
12-35 months<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3 or 4<\/td>\nTreat CDC stage B<\/td>\nTreat WHO stage 4 and severe 3<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\nTreat <25% or <1000 cells\/mm3<\/td>\nTreat <25%<\/td>\nTreat <20% or <750 cells\/mm3<\/td>\n<\/tr>\n
Virological<\/td>\nConsider >100,000 copies\/mL<\/td>\nConsider >100,000 copies\/mL<\/td>\n–<\/td>\n<\/tr>\n
36-59 months<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3 or 4<\/td>\nTreat CDC stage B<\/td>\nTreat WHO stage
\n4 and severe 3<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\nTreat <20% or <500 cells\/mm3<\/td>\nTreat <25%<\/td>\nTreat <20% or
\n<350 cells\/mm3<\/td>\n<\/tr>\n
Virological<\/td>\nConsider >100,000 copies\/mL<\/td>\nConsider >100,000 copies\/mL<\/td>\n–<\/td>\n<\/tr>\n
5 years +<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
Clinical<\/td>\nTreat CDC stage B or C\/WHO stage 3 or 4<\/td>\nTreat CDC stage B
\nor C<\/td>\n		WHO stage 4 or severe 3<\/td>\n<\/tr>\n
Immunological (CD4%\/count)<\/td>\nTreat <350 cells\/mm3<\/td>\nTreat <25% or <500
\ncells\/mm3<\/td>\n		Treat <15% or <200 cells\/mm3<\/td>\n<\/tr>\n
Virological<\/td>\nConsider >100,000 copies\/mL<\/td>\nConsider
\n>100,000 copies\/mL<\/td>\n		–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Other recommendations<\/h2>\n

Recommendations on the use of resistance testing, TDM and HLA\u00a0testing are informed by adult data and paediatric cohorts in Europe. The guidelines highlight the paucity of data from RCTs on which to base\u00a0recommendations for children and note that available trials tend to be small, therefore \u0093\u0085 we continue to rely on cohort studies, extrapolation from adult
\ndata and expert opinion.\u0094 They recommend that wherever possible children should be enrolled in clinical trials.<\/p>\n

Drug information will be available alongside the guideline, and will be kept updated, on the PENTA website:
\nhttp:\/\/www.pentatrials.org<\/a><\/p>\n

COMMENT<\/strong><\/p>\n

WHO paediatric guidance is due for update imminently, and is likely to recommend earlier treatment in line with updated WHO adult\u00a0guidance.<\/strong><\/p>\n

WHO and PENTA will provide different recommendations based on the same data. This reflects both the paucity of high quality evidence from\u00a0randomised clinical trials, on which the guidelines are based, and that PENTA guidelines are intended for use in Europe while WHO guidelines will\u00a0predominantly inform national guidelines in less well resourced countries, where the ability of treatment programmes to deliver care may also be an\u00a0issue.<\/strong><\/p>\n

We intend to summarise and review new WHO paediatric guidance later in 2010 when it is published. PENTA guidelines are not likely to change when\u00a0new WHO paediatric guidance is published, and remain the current recommendations for treating children with HIV in Europe.<\/strong><\/p>\n

Ref: PENTA Steering Committee. PENTA 2009 guidelines for the use of antiretroviral therapy in paediatric infection. HIV Medicine 2009, 10,\u00a0591-613.<\/p>\n","protected":false},"excerpt":{"rendered":"

Polly Clayden, HIV\u00a0i-Base The updated PENTA guidelines were published in the November 2009 edition of HIV Medicine. These guidelines offer practical recommendations for treating\u00a0children with HIV in Europe. The main changes since the 2004 guidelines are: When to start? Universal …<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[23],"tags":[],"class_list":["post-7822","post","type-post","status-publish","format-standard","hentry","category-guidelines"],"_links":{"self":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/7822","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/comments?post=7822"}],"version-history":[{"count":0,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/7822\/revisions"}],"wp:attachment":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/media?parent=7822"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/categories?post=7822"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/tags?post=7822"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}