Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

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The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

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Management of Children Receiving Antiretroviral Therapy

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

Last Updated: April 14, 2020; Last Reviewed: April 14, 2020

Panel's Recommendations for Modifying Antiretroviral Regimens in Children with Sustained Virologic Suppression on Antiretroviral Therapy
Panel's Recommendations
  • Children who have sustained virologic suppression on their current antiretroviral (ARV) regimen should be regularly evaluated for opportunities to change to a new regimen that facilitates adherence, simplifies administration, increases ARV potency or barrier to resistance, and decreases the risk of drug-associated toxicity (AII).
  • Before making changes to a patient’s regimen, clinicians must carefully consider the patient’s previous regimens, past episodes of ARV therapy failure, prior drug resistance test results, drug cost, the patient’s insurance coverage, and the patient’s ability to tolerate the new drug regimen (AIII). Archived drug resistance can limit the antiviral activity of a new drug regimen.
  • Children should be carefully monitored after a change in treatment. Viral load measurement is recommended 2 weeks to 4 weeks after a change in a child’s ARV regimen (BIII).
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

Table 16. Examples of Changes in Antiretroviral Regimen Components for Children with Sustained Virologic Suppression

This list is not exhaustive and does not necessarily contain all potential treatment options. Instead, it provides examples of changes that could be made. The table only includes information about switching between ARV drugs; it does not include all the information that clinicians should consider before prescribing these drugs, such as drug cost and the patient’s insurance coverage. Please refer to individual drug sections, Table 1, and Table 2 in Appendix A: Pediatric Antiretroviral Drug Information for further information about the use of specific ARV drugs and FDC formulations.

Table 16. Examples of Changes in Antiretroviral Regimen Components for Children with Sustained Virologic Suppression
Current ARV Drug(s) Age, Weight, and SMR Requirements Potential ARV Drug Switch Comments
NRTIs
ABC Twice Daily Aged ≥1 year ABC once daily See the Abacavira section.
3TC Twice Daily
Aged ≥3 years 3TC once daily See the Lamivudine section.
Any age (starting at full-term birth)

Any weight
FTC once daily See the Emtricitabine section.
ZDV, ddI, or d4Tb

Note: ddI and d4T should be replaced as soon as possible due to concerns about toxicity.

Aged ≥3 months ABC Less long-term mitochondrial toxicity.

Children aged ≥1 year can take ABC once daily.
Aged ≥2 years

Weighing 17 kg to <25 kg
TDF TDF is a reasonable, once-daily option for HLA-B*5701-positive children for whom ABC is not recommended. TDF is available as an oral powder and low-strength tablets alone or in combination with FTC.
Aged ≥2 years

Weighing ≥25 kg
TAFc Less long-term mitochondrial toxicity. Once-daily dosing. Coformulation with other ARV drugs can further reduce pill burden. TAF is preferred over TDF because of the lower risk of bone and renal toxicity.
NNRTIs
NVP or EFV





Any age (starting at full-term birth)

Weighing ≥2 kg
RALd RAL has a potentially greater barrier to resistance than NVP. Both are dosed twice daily in children.
Aged ≥3 months

Weighing ≥5 kg
ATV/r ATV/r has a potentially greater barrier to resistance; however, taking ATV/r may be difficult for some patients, as ATV oral powder must be mixed with food or a beverage before administration, and the palatability of the RTV oral solution is poor.
Aged ≥3 years

Weighing ≥10 kg
DRV/r DRV/r has a potentially greater barrier to resistance. DRV/r is administered twice daily to patients aged <12 years, but may be administered once daily in children aged ≥12 years who do not have any DRV resistance mutations.
Weighing ≥25 kg BIC as Biktarvy Once-daily dosing. BIC is available as a component of the FDC tablet BIC/FTC/TAF (Biktarvy), which is a complete ARV regimen that can be taken with or without food.
Weighing ≥25 kg EVG as Genvoya EVG is available as a component of the FDC tablet EVG/c/FTC/TAF (Genvoya), which is a complete ARV regimen that must be taken with food.
Weighing ≥20 kg DTG DTG is available as a smaller, single-drug tablet or as an FDC tablet, both of which can be dosed once daily if no INSTI resistance mutations have been previously detected. DTG plus the weight-appropriate dose of FTC/TDF (Truvada) can be used in children weighing 20 kg to <25 kg. DTG is available as a component of the FDC tablet ABC/DTG/3TC (Triumeq), which is a complete ARV regimen that can be given to children weighing ≥25 kg. Higher barrier to resistance, which makes it a good choice for patients who have poor adherence. May improve lipid levels. See the Dolutegravir section for information regarding use of DTG in female adolescents of childbearing potential and pregnant adolescents.e
Aged ≥12 years

Weighing ≥35 kg
RPV Lower incidence of adverse lipid effects.
PIs
LPV/r Twice Daily






Any age (starting at full-term birth)

Weighing ≥2 kg
RALd Better palatability. RAL HD can only be given once daily in those weighing ≥40 kg. Unlike LPV/r, the use of RAL is not restricted to infants with a corrected gestational age of ≥42 weeks and a postnatal age of ≥ 14 days. RAL granules may be difficult to dose for some caregivers.
Aged ≥3 years

Weighing ≥10 kg
EFV Once-daily dosing. Better palatability. Lower incidence of adverse lipid effects. See the Efavirenz section for concerns about EFV dosing for children aged <3 years.
Aged ≥3 months

Weighing ≥5 kg
ATV/r Once-daily dosing. ATV/r may have a lower incidence of adverse lipid effects; however, taking ATV/r may be difficult for some patients, as ATV oral powder must be mixed with food or a beverage before administration, and the palatability of the RTV oral solution is poor.
Aged ≥3 years

Weighing ≥10 kg
DRV/r DRV/r may have a lower incidence of adverse lipid effects. DRV/r is administered twice daily to patients aged <12 years, but may be administered once daily in children aged ≥12 years who do not have DRV resistance mutations.
Weighing ≥25 kg EVG as Genvoya EVG is available as a component of the FDC tablet EVG/c/FTC/TAF (Genvoya), which is a complete ARV regimen that must be taken with food.
Weighing ≥20 kg DTG Once-daily dosing if no INSTI resistance mutations have been previously detected. May be better tolerated, and can be given as an FDC tablet to children weighing ≥25 kg. DTG plus the weight-appropriate dose of FTC/TDF (Truvada) can be used in children weighing 20 kg to <25 kg. May improve lipid levels. See the Dolutegravir section for information regarding use of DTG in female adolescents of childbearing potential and pregnant adolescents.e
Aged ≥12 years

Weighing ≥35 kg
RPV May be better tolerated. Lower incidence of adverse lipid effects.
Weighing ≥25 kg BIC as Biktarvy Once-daily dosing. BIC is available as a component of the FDC tablet BIC/FTC/TAF (Biktarvy), which is a complete ARV regimen that can be taken with or without food.
Other
Any Multi-Pill and/or Twice-Daily Regimen






Weighing ≥25 kg EVG/c/FTC/TAF (Genvoya) Once-daily dosing. Single pill. Alignment with adult regimens. Must be taken with food.
Weighing ≥25 kg FTC/TAFc (Descovy) plus DTG Once-daily dosing. This regimen may be more desirable because of smaller pill sizes, but it has a higher pill burden (two pills instead of one). Aligns a child’s regimen with an efficacious regimen that is used in adults. See the Dolutegravir section for information regarding use of DTG in female adolescents of childbearing potential and pregnant adolescents.e
Weighing ≥35 kg

SMR 4 or 5
EVG/c/FTC/TDF (Stribild) Once-daily dosing. Single pill. Aligns a child’s regimen with an efficacious regimen that is used in adults. Must be taken with food. Renal and bone toxicity of TDF limit its use.
Aged ≥12 years

Weighing ≥35 kg
FTC/RPV/TAF (Odefsey) Once-daily dosing. Single pill. Aligns a child’s regimen with an efficacious regimen that is used in adults. Must be taken with food at a consistent time daily.
Weighing ≥25 kg BIC/FTC/TAF (Biktarvy) Once-daily dosing. Single pill that can be taken with or without food.
Aged ≥12 years

Weighing ≥35 kg

SMR 4 or 5
FTC/RPV/TDF (Complera) Once-daily dosing. Single pill. Aligns a child’s regimen with an efficacious regimen that is used in adults. Must be taken with food at consistent time daily. Renal and bone toxicity of TDF limit its use.
Weighing ≥25 kg ABC/DTG/3TC (Triumeq) Once-daily dosing. Single pill. Aligns a child’s regimen with an efficacious regimen that is used in adults. Large pill size may be a deterrent. See the Dolutegravir section for information regarding use of DTG in female adolescents of childbearing potential and pregnant adolescents.e
Weighing ≥40 kg

SMR 4 or 5
EFV/FTC/TDF (Atripla) Once-daily dosing. Single pill. Aligns a child’s regimen with an efficacious regimen that is used in adults. Renal and bone toxicity of TDF as well as CNS toxicity of EFV limit its use.
a For infants and young children who are being treated with liquid formulations of ABC, initiation with once-daily ABC is not generally recommended. In clinically stable patients with undetectable viral loads who have had stable CD4 counts for >6 months (24 weeks) on twice-daily ABC, the dose can be changed from twice daily to once daily.

b See Archived Drugs in Appendix A: Pediatric Antiretroviral Drug Information.

c For children and adolescents weighing 25 kg to <35 kg, TAF can be used in combination with an INSTI or an NNRTI, but not a boosted PI. For children and adolescents weighing ≥35 kg, TAF can be used in combination with an INSTI, NNRTI, or a boosted PI.

d RAL is recommended for twice-daily use in children. Chewable tablets can be used as dispersible tablets starting at 4 weeks of age. RAL HD once daily is only recommended for virologically suppressed children weighing ≥40 kg.

e Exposure to DTG around the time of conception has been associated with a small but significant increase in the risk of infant neural tube defects. Additional information and specific recommendations about the use of DTG in adolescents and adults who are pregnant and those who are trying to conceive or who may become pregnant are available in the Adult and Adolescent Antiretroviral Guidelines (see Table 6b and Adolescents and Young Adults with HIV) and in the Perinatal Guidelines (see Teratogenicity, Recommendations for Use of Antiretroviral Drugs During Pregnancy, and Appendix D. Dolutegravir Counseling Guide for Health Care Providers).

Key: 3TC = lamivudine; ABC = abacavir; ARV = antiretroviral; ATV = atazanavir; ATV/r = atazanavir/ritonavir; BIC = bictegravir; CD4 = CD4 T lymphocyte cell; CNS = central nervous system; d4T = stavudine; ddI = didanosine; DRV = darunavir; DRV/r = darunavir/ritonavir; DTG = dolutegravir; EFV = efavirenz; EVG = elvitegravir; EVG/c = elvitegravir/cobicistat; FDC = fixed-dose combination; FTC = emtricitabine; HD = high dose; HLA = human leukocyte antigen; INSTI = integrase strand transfer inhibitor; LPV/r = lopinavir/ritonavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; PI = protease inhibitor; RAL = raltegravir; RPV = rilpivirine; RTV = ritonavir; SMR = sexual maturity rating; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; ZDV = zidovudine

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