Antiretroviral Stewardship in a Pediatric HIV Clinic: Development, Implementation and Improved Clinical Outcomes

Abstract

Background: Antiretroviral (ARV) management in pediatrics is a challenging process in which multiple barriers to optimal therapy can lead to poor clinical outcomes. In a pediatric HIV clinic, we implemented a systematic ARV stewardship program to evaluate ARV regimens and make recommendations for optimization when indicated.

Methods: A comprehensive assessment tool was used to screen for issues related to genotypic resistance, virologic/immunologic response, drug-drug interactions, side effects and potential for regimen simplification. The ARV stewardship team (AST) made recommendations to the HIV clinic provider, and followed patients prospectively to assess clinical outcomes at 6 and 12 months.

Results: The most common interventions made by the AST included regimen optimization in patients on suboptimal regimens based on resistance mutations (35.4%), switching to safer ARVs (33.3%) and averting significant drug-drug interactions (10.4%). In patients anticipated to have a change in viral load (VL) as a result of the AST recommendations, we identified a significant benefit in virologic outcomes at 6 and 12 months when recommendations were implemented within 6 months of ARV review. Patients who had recommendations implemented within 6 months had a 7-fold higher probability of achieving a 0.7 log10 reduction in VL by 6 months, and this benefit remained significant after controlling for adherence [adjusted odds ratio: 6.8 (95% confidence interval: 1.03-44.9; P <0.05)].

Conclusions: A systematic ARV stewardship program implemented at a pediatric HIV clinic significantly improved clinical outcomes. ARV stewardship programs can be considered a core strategy for continuous quality improvement in the management of HIV-infected children and adolescents.

Figure 1

Antiretroviral stewardship assessment tool NOTE: ARV = antiretroviral, VL = viral load, IPC = intensive primary care, PI = protease inhibitor

Figure 2

Selection of patients for study inclusion * Included patients in whom a change in CD4 and/or VL was anticipated as a result of the recommendations made by the ARV stewardship team NOTE: ARV = antiretroviral, VL = viral load, IPC = intensive primary care

Figure 3

Change in CD4 count (Panel A) and viral load (Panel B) at 6 and 12 months post-antiretroviral review for 28 patients in which improvement in CD4 count and/or viral load was anticipated as a result of the recommendations made by the antiretroviral stewardship team