Antiretroviral Treatment of HIV-Infected Children

Adapted from
Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection


The pathology and treatment of HIV/AIDS is similar across patient groups. However, children present unique treatment considerations.

Perinatal care

Maternal HIV infection should be identified prior to pregnancy or as early in pregnancy as possible. This provides the best opportunity to prevent infant HIV infection and to identify and start therapy as soon as possible in infants who become infected. Universal HIV counseling and voluntary HIV testing are recommended as the standard of care for all pregnant women in the United States by The Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children.

HIV testing in infants

When to Initiate Antiretroviral Therapy in HIV-Infected Children
Age
Criteria
Recommendation
<12 months Regardless of clinical symptoms, immune status, or viral load Urgent treatment <12 weeks of age
1 to <6 years CDC Stage 3-defining opportunistic illnesses Urgent treatment
  CDC Stage 3 immunodeficiency: CD4 <500 cells/mm3 Urgent treatment
  Moderate HIV-related symptoms Treat
  HIV RNA >100,000 copies/mL Treat
  CD4 cell countd 500–999 cells/mm3 Treat
  Asymptomatic or mild symptoms and CD4 cell count ≥1000 cells/mm3 Consider Treatment
>6 years CDC Stage 3-defining opportunistic illnesses Urgent treatment
  CDC Stage 3 immunodeficiency:d CD4 <200 cells/mm3 Urgent treatment
  Moderate HIV-related symptoms Treat
  HIV RNA >100,000 copies/mL Treat
  CD4 cell countd 200–499 cells/mm3 Treat for CD4 cell count <350 cells/mm3
  Asymptomatic or mild symptoms and CD4 cell count ≥500 cells/mm3 Consider treatment

Initiating Combination Antiretroviral Therapy (cART) — Factors

cART Regimens Recommended for Initial Therapy of Antiretroviral-Naive
Infants & Children
Initial cART in treatment-naive children should include a Preferred agent plus a Dual-nucleoside/nucleotide reverse transcriptase inhibitor backbone combination.
Age
Preferred agent
Plus
Dual-nucleoside/nucleotide reverse transcriptase inhibitor backbone

Neonate & Children <3 years

lopinavir or ritonavir
Age
Agents
Infants <3 months zidovudine plus (lamivudine or emtricitabine)
≥3 months

Either:

  • abacavir plus (lamivudine or emtricitabine)
  • zidovudine plus (lamivudine or emtricitabine)
Children >3 years but <6 years
efavirenz or lopinavir or ritonavir >12 years abacavir plus lamivudine or plus emtricitabine
Children aged ≥6 years
atazanavir/ritonavir or efavirenz or lopinavir/ritonavir
  • abacavir - HLA-B*5701 genetic testing should be performed before initiating abacavir-based therapy, and abacavir should not be given to a child who tests positive for HLA-B*5701
  • lamivudine or emtricitabine - Both emtricitabine and lamivudine have antiviral activity and efficacy against hepatitis B

 

Stage-3-Defining Opportunistic Illnesses In HIV Infection
  • Bacterial infections, multiple or recurrenta
  • Candidiasis of bronchi, trachea, or lungs
  • Candidiasis of esophagus
  • Cervical cancer, invasive
  • Coccidioidomycosis, disseminated or extrapulmonary
  • Cryptococcosis, extrapulmonary
  • Cryptosporidiosis, chronic intestinal (>1 month duration)
  • Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
  • Cytomegalovirus retinitis (with loss of vision)
  • Encephalopathy attributed to HIV
  • HSV: chronic ulcers (>1 month duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1 month)
  • Histoplasmosis, disseminated or extrapulmonary
  • Isosporiasis, chronic intestinal (>1 month duration)
  • Kaposi sarcoma
  • Lymphoma, Burkitt (or equivalent term)
  • Lymphoma, immunoblastic (or equivalent term)
  • Lymphoma, primary, of brain
  • Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary
  • Mycobacterium tuberculosis of any site, pulmonary, disseminated, or extrapulmonary
  • Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
  • Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia
  • Pneumonia, recurrent
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia, recurrent
  • Toxoplasmosis of brain, onset at age >1 month
  • Wasting syndrome attributed to HIV

a Only among children aged <6 years.

b Only among adults, adolescents, and children aged ≥6 years.

 



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