Antiretroviral Stewardship in a Pediatric HIV Clinic: Development, Implementation, and Improved Clinical Outcomes
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.
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.
- 1 The Johns Hopkins Hospital, Department of Pharmacy, Division of Pediatric Pharmacy, Baltimore, MD, USA
- 2 Howard University College of Medicine, Washington, DC, USA
- 3 Medical University of South Carolina, Charleston, SC, USA
- 4 The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of General Pediatrics & Adolescent Medicine, Baltimore, MD, USA
- 5 The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, USA.
- Pediatr Infect Dis J. 2016 Feb 19.
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