Patient Care and Management

Before starting ART, children underwent a general examination including history, physical examination, chest X-ray and performing necessary laboratory tests (full blood count, liver enzymes, and CD4 count). HIV viral load testing was not routinely performed unless the patient does not respond to therapy. Comprehensive counseling for caregivers about ART adherence and side effects was provided.

ART initiation for HIV-infected children was indicated based on the child’s clinical stage and CD4 percentage according to the World Health Organization (WHO) guideline criteria in 2006 and the HIV diagnosis and treatment guidelines of the Ministry of Health in Vietnam.17,18 During the study period, the national guideline of HIV/AIDS treatment in Vietnam was changed from version 2006 to version 2015 (ART was given to all HIV-infected children ≥ 5 years of age with CD4 cell count ≤500 cells/mm,3 regardless of WHO clinical stage) and version 2017 (ART should be initiated in all HIV-infected children, regardless of CD4 cell count and WHO clinical stage) according to the WHO consolidated guidelines on the use of ARV drugs for treating and preventing HIV infection.19,20

Co-trimoxazole prophylaxis was given to all patients regardless of CD4 percentage levels. Besides, children under 2 years of age with HIV-tuberculosis co-infection received ART regardless of the CD4 counts. The first-line ART regimen was stavudine (D4T) or zidovudine (AZT) plus lamivudine (3TC) plus nevirapine (NVP) or efavirenz (EFZ). In patients with severe anemia (hemoglobin less than 8g/dL), AZT is replaced by D4T or abacavir (ABC). The lopinavir/ritonavir (LPV/r) was given to children already receiving NVP to prevent mother-to-child transmission of HIV (since 2010). For patients with combined TB infection, the first-line ART was started 2–8 weeks after anti-tuberculous therapy. A combination of three nucleoside reverse transcriptase inhibitors (AZT + 3TC + ABC) was prescribed for those weighing less than 10 kg and/or for those less than 3 years old; a combination of three antiretroviral drugs (AZT or D4T + 3TC + EFZ) was provided for children weighing ≥ 10 kg and/or for those ≥ 3 years of age. The patients with clinical, immunological or virological failures will be switched to second-line regimens (containing LPV/r).