lRENAL IMPAIRMENT
Dose adjustmentsReduce dose; consult product literature.
lMONITORING REQUIREMENTS
▶Monitor electrolytes, particularly calcium and magnesium.
▶Monitor serum creatinine every second day during
induction and every week during maintenance.
lDIRECTIONS FOR ADMINISTRATIONAvoid rapid infusion.
Forintravenous infusion, give undiluted solution via a
central venous catheter; alternatively dilute to a
concentration of 12 mg/mL with Glucose 5 %orSodium
Chloride 0. 9 % for administration via a peripheral vein;
give over at least 1 hour (give doses greater than 60 mg/kg
over 2 hours).
lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Solution for infusion
ELECTROLYTES:May contain Sodium
▶Foscavir(Clinigen Healthcare Ltd)
Foscarnet sodium 24 mg per 1 mlFoscavir 6 g/ 250 ml solution for
infusion bottles| 1 bottleP£ 119. 85 (Hospital only)
6.4 HIV infection
HIV infection
Overview
There is no cure for infection caused by the human
immunodeficiency virus (HIV) but a number of drugs slow or
halt disease progression. Drugs for HIV infection
(antiretrovirals) may be associated with serious side-effects.
Although antiretrovirals increase life expectancy
considerably and decrease the risk of complications
associated with premature ageing, mortality and morbidity
remain slightly higher than in uninfected individuals.
The natural progression of HIV disease is different in
children compared to adults; drug treatment should only be
undertaken by specialists within a formal paediatric HIV
clinical network. Guidelines and dose regimens are under
constant review and for this reason some dose
recommendations have not been included inBNF for
Children.
Further information on the management of children with
HIV can be obtained from the Children’s HIV Association
(CHIVA)www.chiva.org.uk; and further information on
antiretroviral use and toxicity can be obtained from the
Paediatric European Network for Treatment of AIDS
(PENTA) websitepenta-id.org/.
Aims of treatment
Treatment is aimed at suppressing viral replication for as
long as possible; it should be started before the immune
system is irreversibly damaged. The need for early drug
treatment should, however, be balanced against the risk of
toxicity. Commitment to treatment and strict adherence
over many years are required; the regimen chosen should
take into account convenience and the child’s tolerance of
treatment. The development of drug resistance is reduced by
using a combination of drugs; such combinations should
have synergistic or additive activity while ensuring that their
toxicity is not additive. It is recommended that viral
sensitivity to antiretroviral drugs is established before
starting treatment or before switching drugs if the infection
is not responding.
Initiation of treatment
Treatment is started in all HIV infected children under 1 year
of age regardless of clinical and immunological parameters.
In children over 1 year of age, treatment is based on the
child’s age, CD 4 cell count, viral load, and symptoms. The
choice of antiviral treatment for children should take into
account the method and frequency of administration, risk of
side-effects, compatibility of drugs with food, palatability,
and the appropriateness of the formulation. Initiating
treatment with a combination of drugs (‘highly active
antiretroviral therapy’which includes 2 nucleoside reverse
transcriptase inhibitors witheithera non-nucleoside reverse
transcriptase inhibitorora boosted protease inhibitor) is
recommended. Abacavir p. 416 and lamivudine p. 420 are the
nucleoside reverse transcriptase inhibitors of choice for
initial therapy; however, zidovudine p. 422 and lamivudine
are used in children who are positive for the HLA-B* 5701
allele. Nevirapine p. 414 is the preferred non-nucleoside
reverse transcriptase inhibitor in children under 3 years of
age, but efavirenz p. 413 is preferred in older children.
Lopinavir with ritonavir p. 425 is the preferred boosted
protease inhibitor for initial therapy. The metabolism of
many antiretrovirals varies in young children; it may
therefore be necessary to adjust the dose according to the
plasma-drug concentration. Children who require treatment
for both HIV and chronic hepatitis B should receive antivirals
that are active against both diseases.HIV infection, switching therapy
Deterioration of the condition (including clinical, virological
changes, and CD 4 cell changes) may require a complete
change of therapy. The choice of an alternative regimen
depends on factors such as the response to previous
treatment, tolerance, and the possibility of cross-resistance.HIV infection and pregnancy
Treatment of HIV infection in pregnancy aims to reduce the
risk of toxicity to the fetus (although information on the
teratogenic potential of most antiretroviral drugs is limited),
to minimise the viral load and disease progression in the
mother, and to prevent transmission of infection to the
neonate.All treatment options require careful
assessment by a specialist. Combination antiretroviral
therapy maximises the chance of preventing transmission
and represents optimal therapy for the mother. However, it
may be associated with a greater risk of preterm delivery.
Local protocols and national guidelines (www.bhiva.org)
should be consulted for recommendations on treatment
during pregnancy and the perinatal period. Pregnancies in
HIV-positive women and babies born to them should be
reported prospectively to the National Study of HIV in
Pregnancy and Childhood atwww.ucl.ac.uk/nshpc/and to the
Antiretroviral Pregnancy Registry atwww.apregistry.com.HIV infection and breast-feeding
Breast-feeding by HIV-positive mothers may cause HIV
infection in the infant and should be avoided.HIV infection, post-exposure prophylaxis
Children exposed to HIV infection through needlestick
injury or by another route should be sent immediately to an
accident and emergency department for post-exposure
prophylaxis [unlicensed indication]. Antiretrovirals for
prophylaxis are chosen on the basis of efficacy and potential
for toxicity. Recommendations have been developed by the
Children’s HIV Association,www.chiva.org.uk.Drug treatment
Zidovudine, a nucleoside reverse transcriptase inhibitor (or
‘nucleoside analogue’), was thefirst anti-HIV drug to be
introduced. Other nucleoside reverse transcriptase inhibitors
include abacavir, didanosine p. 417 , emtricitabine p. 418 ,
lamivudine, stavudine p. 421 , and tenofovir disoproxil
p. 421. There are concerns about renal toxicity and effects on
bone mineralisation when tenofovir disoproxil is used in
prepubertal children.BNFC 2018 – 2019 HIV infection 409
Infection5