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Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

Management of Children Receiving Antiretroviral Therapy

Modifying Antiretroviral Regimens in Children with Sustained Virologic Suppression on Antiretroviral Therapy

(Last updated: February 12, 2014; last reviewed: February 12, 2014)

Panel's Recommendations

Panel's Recommendations

  • For children who have sustained virologic suppression on their current regimen, changing to a new antiretroviral regimen with improved pill burden or tolerance should be considered in order to facilitate continued adherence and increase safety (BII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = expert opinion
 Studies that include children or children /adolescents, but not studies limited to post-pubertal adolescents

Initial ARV regimens are chosen based on safety, pharmacokinetic and efficacy data for drugs available in formulations suitable for the age of the child at initiation of cART. New ARV options may become available as children grow and learn to swallow pills and as new drugs, drug formulations and data become available. For children who have sustained virologic suppression on their current regimen, changing to a new ARV regimen may be considered in order to permit use of pills instead of liquids, reduce pill burden, allow use of once-daily medications, reduce risk of adverse effects, and align their regimens with widely used, efficacious adult regimens.

Several studies have addressed switching ARV regimen components in children with sustained virologic suppression. Based on the NEVEREST study, young children (aged <3 years) with virologic suppression who switch from ritonavir-boosted lopinavir to nevirapine can maintain virologic suppression as well as those who continue ritonavir-boosted lopinavir, provided there is good adherence and no baseline resistance to nevirapine.1,2 By extrapolation, replacement of ritonavir-boosted lopinavir with efavirenz, another non-nucleoside reverse transcriptase inhibitor (NNRTI), another protease inhibitor, raltegravir, or another integrase inhibitor would likely be effective, but this has not been directly studied. Several small studies have demonstrated sustained virologic suppression and reassuring safety outcomes when drugs that have greater long-term toxicity risk are replaced with drugs that are thought to have less toxicity risk (e.g., replacing stavudine with tenofovir or zidovudine; replacing protease inhibitor with NNRTI), including improved lipid profiles, in small cohorts of children.3-7 Small studies have shown that children with virologic suppression on twice-daily regimens maintain virologic suppression if abacavir dosing is changed from twice daily to once daily (see Abacavir drug section) but show mixed results when switching ritonavir-boosted lopinavir dosing from twice daily to once daily.8,9 

Table 12 displays examples of changes in ARV regimen components that are made for reasons of simplification, convenience and safety profile in children who have sustained virologic suppression on their current regimen. When considering such a change, it is important to ensure that a child does not have virologic treatment failure. It is also critical to consider past episodes of ARV treatment failure and all prior drug resistance testing results in order to avoid choosing new ARV drugs for which archived drug resistance would limit activity. The evidence supporting many of these ARV changes is indirect, extrapolated from data about drug performance in initial therapy or follow-on therapy after treatment failure. When such changes are made, careful monitoring is important to ensure that virologic suppression is maintained.

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Table 12: Examples of Changes in ARV Regimen Components That Are Made for Reasons of Simplification, Convenience, and Safety Profile in Children Who Have Sustained Virologic Suppression on Their Current Regimen
ARV Drug(s)
Current Age
Body Size Attained Potential ARV Regimen Change
ZDV or ddI (or d4T*)
≥1 year
N/A ABC Once-daily dosing (see Abacavir in Appendix A: Pediatric Antiretroviral Drug Information for full discussion). Less long-term mitochondrial toxicity. 
ABC Twice Daily
≥1 year
Any ABC once daily
See Abacavir in Appendix A: Pediatric Antiretroviral Drug Information for full discussion.
≥1 year
≥3 kg
RAL Better palatability. Less adverse lipid effect.
LPV/r Twice Daily
≥3 years
N/A EFV Once-daily dosing. Better palatability. Less adverse lipid effect. See Efavirenz in Appendix A: Pediatric Antiretroviral Drug Information regarding concerns about dosing for children < 3 years old.
LPV/r Twice Daily
≥6 years
15 kg ATV/r Once-daily dosing. Lower pill burden. Less adverse lipid effect
ZDV or ddI
Pubertal maturity
(Tanner IV or V)

TDF or ABC Once-daily dosing. Less long-term mitochondrial toxicity. Coformulation with other ARVs can further reduce pill burden.
LPV/r Twice Daily
≥12 years
40 kg DRV/r Once-daily dosing possible. Lower pill burden.
Any Adolescence
  • Pubertal maturity (Tanner IV or V)
Once-daily dosing. Single pill. Alignment with adult regimens.
* Because of concerns about long-term adverse effects, d4T may be replaced by a safer drug even before sustained virologic suppression is achieved (see Stavudine in Appendix A: Pediatric Antiretroviral Drug Information).

Key to Acronyms: ABC = abacavir, ATV/r = ritonavir-boosted atazanavir, COBI = cobicistat, d4T = stavudine, ddI = didanosine, DRV/r = ritonavir-boosted darunavir, EFV = efavirenz, EVG = elvitegravir, FTC = emtricitabine, LPV/r = ritonavir-boosted lopinavir, RAL = raltegravir, TDF = tenofovir disoproxil fumarate, ZDV = zidovudine


  1. Coovadia A, Abrams EJ, Stehlau R, et al. Reuse of nevirapine in exposed HIV-infected children after protease inhibitor-based viral suppression: a randomized controlled trial. JAMA. Sep 8 2010;304(10):1082-1090. Available at
  2. Kuhn L, Coovadia A, Strehlau R, et al. Switching children previously exposed to nevirapine to nevirapine-based treatment after initial suppression with a protease-inhibitor-based regimen: long-term follow-up of a randomised, open-label trial. Lancet Infect Dis. Jul 2012;12(7):521-530. Available at
  3. Vigano A, Aldrovandi GM, Giacomet V, et al. Improvement in dyslipidaemia after switching stavudine to tenofovir and replacing protease inhibitors with efavirenz in HIV-infected children. Antivir Ther. 2005;10(8):917-924. Available at
  4. Fabiano V, Giacomet V, Vigano A, et al. Long-term body composition and metabolic changes in HIV-infected children switched from stavudine to tenofovir and from protease inhibitors to efavirenz. Eur J Pediatr. Aug 2013;172(8):1089-1096. Available at
  5. Rosso R, Nasi M, Di Biagio A, et al. Effects of the change from Stavudine to tenofovir in human immunodeficiency virus-infected children treated with highly active antiretroviral therapy: studies on mitochondrial toxicity and thymic function. Pediatr Infect Dis J. Jan 2008;27(1):17-21. Available at
  6. Aurpibul L, Puthanakit T, Sirisanthana T, Sirisanthana V. Haematological changes after switching from stavudine to zidovudine in HIV-infected children receiving highly active antiretroviral therapy. HIV Med. May 2008;9(5):317-321. Available at
  7. Gonzalez-Tome MI, Amador JT, Pena MJ, Gomez ML, Conejo PR, Fontelos PM. Outcome of protease inhibitor substitution with nevirapine in HIV-1 infected children. BMC Infect Dis. 2008;8:144. Available at
  8. Foissac F, Blanche S, Dollfus C, et al. Population pharmacokinetics of atazanavir/ritonavir in HIV-1-infected children and adolescents. Br J Clin Pharmacol. Dec 2011;72(6):940-947. Available at
  9. Chokephaibulkit K, Prasitsuebsai W, Wittawatmongkol O, et al. Pharmacokinetics of darunavir/ritonavir in Asian HIV-1-infected children aged >/=7 years. Antivir Ther. 2012;17(7):1263-1269. Available at

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