Page 51 - AIDSBK23C

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Children 3 to <5 yr Treat all children with CDC class B or C disease

Treat all children with CD4 <20% or <500/µL

Closer monitoring if HIV-1 RNA load >100,000 copies/mL

Children and adolescents Treat all with CDC class B or C disease
5 yr or more
Treat all with CD4 <350/µL

The ART regimens may include combinations of one or more of a nucleoside reverse
transcriptase inhibitor (NRTI), nucleotide reverse transcriptase inhibitor (NtRTI) non-nucleoside
reverse transcriptase inhibitor (NNRTI), and protease inhibitor (PI). Various combinations are
possible, based upon clinical trials that determine efficacy, adverse effects, interactions, and ease
of use. The standard recommended regimens are as follows: [256,281]

Standard ART Regimens

* NRTI + NRTI + NNRTI
* NtRTI + NRTI
* NtRTI + NNRTI
* NRTI + NRTI + PI
* NRTI + NRTI + PI + PI

With ART, the CD4 count typically increases.[256] . The use of ART can reduce the
total health care cost for persons with AIDS.[283] Despite ART, the reconstitution of the
immune system may be partial or incomplete, with considerable variability in the magnitude of
the response. CD4 counts may remain below normal. Persons with higher baseline HIV-1 RNA
levels and more acute, pre-therapy CD4 cell decreases have greater CD4 cell increases following
institution of ART. However, some patients continue to have good suppression of HIV
replication in spite of no or only a modest increase in the CD4 cell count. Half of persons
starting ART may not suppress the HIV-1 RNA level below 400 copies/mL. Persons older than
50 years of age have more adverse reactions, but better virological responses, to ART compared
with younger patients. Though their initial immunological responses are blunted, after 3 years
they have similar CD4 T-cell counts as younger persons.[284]
In persons with significant immune reconstitution in response to antiretroviral therapy,
there may be a paradoxical accelerated clinically apparent presentation to latent, smoldering, or
subclinical infections or to relapse of ongoing treated infections because of an increased
inflammatory response. This is known as immune restoration disease (IRD) or immune
reconstitution inflammatory syndrome (IRIS). Immune reconstitution is defined as a CD4
lymphocyte count >200/µL and an increase of ≥100/µL over baseline any time since starting
antiretroviral therapy. IRD can be characterized by an atypical presentation of a current or past
opportunistic infection or tumor in an HIV-infected persons responding to ART, along with a
decrease in plasma HIV-1 RNA.[285,286]
Additional inflammatory features of IRD include a polyclonal hypergammaglobulinemia
and autoimmune phenomena. Features can include high levels of CD8 lymphocytes, high levels