title: Antiretroviral Stewardship in a Pediatric HIV Clinic: Development, Implementation and Improved Clinical Outcomes.
abstract: 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.
  
  
  
  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.
  
  
  
  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)].
  
  
  
  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.
authors.affiliation: From the *Division of Pediatric Pharmacy, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland; †Howard University College of Medicine, Washington, DC; ‡Medical University of South Carolina, Charleston, South Carolina; §Division of General Pediatrics & Adolescent Medicine, and ¶Division of Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Alice J
authors.initials: AJ
authors.lastname: Hsu
authors.forename: Asha
authors.initials: A
authors.lastname: Neptune
authors.forename: Constants
authors.initials: C
authors.lastname: Adams
authors.forename: Nancy
authors.initials: N
authors.lastname: Hutton
authors.forename: Allison L
authors.initials: AL
authors.lastname: Agwu
mesh_terms: D000293:Adolescent; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D002648:Child; D004363:Drug Utilization / Q000592:standards*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006776:Hospitals, Pediatric; D006801:Humans; D008297:Male; D011446:Prospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents