Initiating Antiretroviral Therapy
The natural history of HIV infection in adolescents has not been fully defined. Long-term survivors of perinatal infection may have a unique clinical course that differs from that of other adolescents.4 However, most adolescents are infected, by sexual contact or injection drug use, after their immune systems have developed to maturity. In these adolescents, the clinical course of HIV infection parallels that of adults rather than of children, though there may be subtle differences in the adolescent immune system.5
In identifying and addressing the clinical needs of each HIV-infected adolescent, the following 10 care domains form the basis of an effective treatment protocol.5 For a detailed description of each domain, see "Adolescent HIV Care Protocol" in the Toolbox.
- Medical and physical history
- Review of systems
- Physical examination
- Laboratory assessment
- Access to clinical research
- Entitlements/case management
- Patient education and empowerment
- Referral to support services
In terms of ART, currently recommended strategies strike a balance between initiating treatment early enough to preserve immune function yet waiting long enough to minimize the time a patient is taking medications, as most ARVs have potentially serious side effects. Although the issues involved in making decisions about implementing ART are complex, a number of guidelines from expert panels are available to help care providers select effective regimens for individual patients. All clinicians treating HIV-infected patients should be familiar with the most current versions of these treatment guidelines (see Toolbox).
For youth experiencing developmental changes and growth spurt, drug dosing should be carefully monitored to avoid potential side effects and toxicities, as well as inadequate dosing (see "Pediatric ARV Guidelines" in the Toolbox). In general, pubertal changes may affect pharmacokinetics. Therefore, ARV dosing should be based on the Tanner puberty stage and not on age:
- Adolescents who have entered puberty or are early in puberty (Tanner stage I/II) should receive pediatric dosing based on pediatric guidelines.
- Adolescents who are in the middle of puberty (Tanner stage III/IV) should receive dosages based on whether they have completed their growth spurt.
- Adolescents who have completed puberty (Tanner stage V) should be given adult dosages.
ART CLASS 101
- CD4 cell count and symptoms and clinical status are the keys in determining when to recommend that a patient begin ART.
- For asymptomatic patients, the CD4 cell count is the major determinant of the need for ART.
- Certain conditions or comorbidities (eg, pregnancy, hepatitis B, HIV-associated nephropathy) may be indications for ART.
- HIV resistance testing generally should be obtained as soon as possible after infection is diagnosed so that in the future the best possible medication regimen can be selected.
- For asymptomatic patients, the current CDC guidelines recommend starting ART in patients with CD4 counts of less than 350 cells/µL, and suggest individualizing treatment decisions in patients with CD4 counts of more than 350 cells/µL.
- An important advance in treatment options is the availability of several medication regimens that allow once-daily dosing.
- Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. July 29, 2008. 1-134.
- Ryan C, Futterman D. Lesbian and Gay Youth. New York: Columbia University Press; 1998.