Simplified HIV Treatment Guidelines for Children
All HIV-infected children should receive combination antiretroviral therapy (cART) with at least three drugs—specifically two NRTIs plus one protease inhibitor—to maximally suppress viral replication and preserve immune function. 1
When to Start Treatment
Infants Under 12 Months
- Start treatment immediately upon confirmed HIV diagnosis, regardless of symptoms, CD4 count, or viral load 1
- Infants are at highest risk for rapid disease progression 1
- Critical consideration: Assess caregiver adherence capacity before initiating therapy, as subtherapeutic drug levels (especially protease inhibitors) rapidly lead to resistance 1
Children 1 Year and Older
Treat immediately if ANY of the following:
- Any HIV symptoms (clinical categories A, B, or C) 1
- Evidence of immune suppression (immune categories 2 or 3) 1
- HIV RNA >100,000 copies/mL (high mortality risk at any age) 1
- HIV RNA >10,000-20,000 copies/mL in children ≥30 months 1
- Substantial viral load increase on repeat testing:
May defer treatment only if ALL of the following:
- Asymptomatic 1
- Normal immune status 1
- Low viral load 1
- Concerns about adherence, safety, or treatment persistence 1
- If deferring: Monitor virologic, immunologic, and clinical status regularly 1
What Medications to Use
Standard Regimen
Two NRTIs + one protease inhibitor 1
- This combination slows disease progression, improves survival, achieves greater viral suppression, and delays resistance development 1
- Goal: Reduce HIV RNA to undetectable levels 1
Available Protease Inhibitors for Young Children
- Nelfinavir (Viracept): Powder formulation that mixes with water or food 1
- Ritonavir (Norvir): Liquid formulation 1
- Lopinavir/ritonavir oral solution: 80 mg/20 mg per mL 2
Dosing by Age
Infants 14 days to 6 months:
- Lopinavir/ritonavir 300/75 mg/m² twice daily with food 2
Children 6 months to 12 years:
- Lopinavir/ritonavir 300/75 mg/m² twice daily with food (without nevirapine) 2
- Adjust dose based on body weight changes 2
Children ≥12 years and ≥35 kg:
- Tenofovir 300 mg once daily (can be taken without regard to food) 3
What NOT to Use
- Never use monotherapy for HIV treatment (except ZDV alone during first 6 weeks of life for prevention of perinatal transmission) 1
- Infants identified as HIV-infected while receiving ZDV prophylaxis must switch to combination therapy 1
When to Change Treatment
Immunologic Failure
- Change in immune classification category 1
- For CD4 <15%: Persistent decline of ≥5 percentiles (e.g., 15%→10% or 10%→5%) 1
- Rapid substantial decrease in absolute CD4 count (>30% decline in <6 months) 1
- Confirm with repeat measurement at least 1 week after initial test 1
Clinical Failure
- Progressive neurodevelopmental deterioration (impaired brain growth, declining cognitive function, motor dysfunction) 1
- New regimen should include drugs with CNS penetration (ZDV or nevirapine with CSF/plasma ratio >0.5) 1
- Growth failure despite adequate nutrition 1
- Disease progression to more advanced clinical category 1
Changing Regimen Principles
- For toxicity: Switch to agents with different toxicity profiles 1
- For treatment failure: Change to drugs the patient hasn't received before 1
- Consider impact on future treatment options 1
Critical Adherence Considerations
- Adherence is paramount: Incomplete adherence and subtherapeutic drug levels enhance resistance development, particularly with protease inhibitors 1
- Involve caregivers and child in decision-making process 1
- Therapy is most effective in treatment-naïve patients who lack resistant viral strains 1
- Take lopinavir/ritonavir oral solution with food to enhance absorption 2
- Use calibrated dosing cup or oral syringe for accurate dosing 2
Common Pitfalls to Avoid
- Don't delay treatment in infants <12 months waiting for symptoms or lab changes—they progress rapidly 1
- Don't use triple nucleoside-only regimens—early virologic failure has been reported 1
- Don't combine with other tenofovir-containing products (ATRIPLA, COMPLERA, DESCOVY, GENVOYA, ODEFSEY, STRIBILD, TRUVADA, VEMLIDY) 3
- Don't forget to test for HIV before starting HBV treatment with tenofovir—it must be part of appropriate combination therapy in HIV-infected patients 3
Monitoring Requirements
- Assess renal function (creatinine clearance) before starting tenofovir 3
- In patients at renal risk: Monitor creatinine clearance, serum phosphorus, urine glucose, and urine protein periodically 3
- Monitor for bone mineral density changes in patients with fracture history or osteoporosis risk 3
- Regular virologic and immunologic monitoring to assess treatment response 1