Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

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.

  •   Table of Contents

Download Guidelines

Adherence to Antiretroviral Therapy in Children and Adolescents Living with HIV

Last Updated: May 22, 2018; Last Reviewed: May 22, 2018

Panel's Recommendations for Adherence to Antiretroviral Therapy in Children and Adolescents Living with HIV
Panel's Recommendations
  • Strategies to maximize adherence should be discussed before initiation of antiretroviral therapy (ART) and again before changing regimens (AIII).
  • Adherence to therapy must be assessed and promoted at each visit, along with continued exploration of strategies to maintain and/or improve adherence (AIII).
  • At least one method of measuring adherence to ART should be used in addition to monitoring viral load (AIII).
  • Once-daily antiretroviral regimens and regimens with low pill burden should be prescribed whenever feasible (AII*).
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 13. Evidence-Based Approaches for Monitoring Medication Adherence
Routine Assessment of Medication Adherence in Clinical Carea Description
Monitor viral load. Viral load monitoring should be done more frequently after initiating or changing medications.a
Assess quantitative self-report of missed doses. Ask patient and/or caregiver about the number of missed doses over defined period (1, 3, or 7 days).
Elicit description of medication regimen. Ask patient and/or caregiver about the name/appearance, number, frequency of medications.
Assess barriers to medication administration. Engage the patient and caregiver in dialogue around facilitators and challenges to adherence.
Monitor pharmacy refills. Approaches include pharmacy-based or clinic-based assessment of on-time medication refills.
Conduct announced and unannounced pill counts. Approaches include asking patients to bring medications to clinic or home visits, or referral to community health nursing.
Targeted Approaches to Monitor Adherence in Special Circumstances Description
Implement DOT. Include brief hospitalization if indicated.
Measure plasma drug concentration. Can be considered for particular drugs.b
Approaches to Monitor Medication Adherence in Research Settings Description
Measure drug concentrations in hair. Good measure of adherence over time.c
Use electronic monitoring devices. MEMS caps, Wisepill
Use mobile phone-based technologies. Interactive voice response, SMS text messaging, mobile apps
See Clinical and Laboratory Monitoring After Initiation of Combination Antiretroviral Therapy (or After a Change in Combination Antiretroviral Therapy) regarding the frequency of adherence assessment after initiating or changing therapy.
See Role of Therapeutic Drug Monitoring in Management of Pediatric HIV Infection regarding indications for therapeutic drug monitoring.
c Sources:
  1. Olds PK, Kiwanuka JP, Nansera D, et al. Assessment of HIV antiretroviral therapy adherence by measuring drug concentrations in hair among children in rural Uganda. AIDS Care. 2015;27(3):327-332. Available at https://www.ncbi.nlm.nih.gov/pubmed/25483955.48
  2. Chawana TD, Gandhi M, Nathoo K, et al. defining a cutoff for atazanavir in hair samples associated with virological failure among adolescents failing second-line antiretroviral treatment. J Acquir Immune Defic Syndr. 2017;76(1):55-59. Available at https://www.ncbi.nlm.nih.gov/pubmed/28520618.49
  3. Pintye J, Bacchetti P, Teeraananchai S, et al. brief report: lopinavir hair concentrations are the strongest predictor of viremia in HIV-infected Asian children and Aadolescents on second-line antiretroviral therapy. J Acquir Immune Defic Syndr. 2017. Available at https://www.ncbi.nlm.nih.gov/pubmed/28825944.18
Key to Acronyms: apps = applications; DOT = directly observed therapy; MEMS = Medication Event Monitoring System

Table 14. Strategies to Improve Adherence to Antiretroviral Medications
Initial Intervention Strategies
  • Establish trust and identify mutually acceptable goals for care.
  • Obtain explicit agreement on the need for treatment and adherence.
  • Identify depression, low self-esteem, substance abuse, or other mental health issues in the child/adolescent and/or caregiver that may decrease adherence. Evaluate and initiate treatment for mental health issues before starting ARV drugs, if possible.
  • Identify family, friends, health team members, and others who can support adherence.
  • Educate patient and family about the critical role of adherence in therapy outcome, including the relationship between partial adherence and resistance and potential impact on future drug regimen choices. Develop a treatment plan that the patient and family understand and to which they feel committed.
  • Work with the patient and family to make specific plans for taking medications as prescribed and supporting adherence. Assist them to arrange for administration in day care, school, and other settings, when needed. Consider home delivery of medications.
  • Establish readiness to take medication through practice sessions or other means.
  • Schedule a home visit to review medications and determine how they will be administered in the home setting.
  • In certain circumstances, consider a brief period of hospitalization at the start of therapy for patient education and to assess tolerability of medications chosen.
Medication Strategies
  • Choose the simplest regimen possible, reducing dosing frequency, pill size, and number of pills.
  • When choosing a regimen, consider the daily and weekly routines and variations in patient and family activities.
  • Choose the most palatable medicine possible (pharmacists may be able to add syrups or flavoring agents to increase palatability).
  • Choose drugs with the fewest AEs; provide anticipatory guidance for management of AEs.
  • Simplify food requirements for medication administration.
  • Prescribe drugs carefully to avoid adverse drug-drug interactions.
  • Assess pill-swallowing capacity and offer pill-swallowing training and aids (e.g., pill-swallowing cup, pill glide). Adjust pill size as needed.
Follow-Up Intervention Strategies
  • Have more than one member of the multidisciplinary team monitor adherence at each visit and in between visits by telephone, email, text, and social media, as needed.
  • Provide ongoing support, encouragement, and understanding of the difficulties associated with maintaining adherence to daily medication regimens.
  • Use patient education aids including pictures, calendars, and stickers.
  • Encourage use of pill boxes, reminders, mobile apps, alarms, and timers.
  • Provide follow-up clinic visits, telephone calls, and text messages to support and assess adherence.
  • Provide access to support groups, peer groups, or one-on-one counseling for caregivers and patients, especially for those with known depression or drug use issues that are known to decrease adherence.
  • Provide pharmacist-based adherence support, such as medication education and counseling, blister packs, refill reminders, automatic refills, and home delivery of medications.
  • Consider DOT at home, in the clinic, or in certain circumstances, such as during a brief inpatient hospitalization.
  • Consider gastrostomy tube use in certain circumstances.
  • Information on other interventions to consider can be found at the Complete Listing of Medication Adherence Evidence-Based Behavioral Interventions.
  • Consult the CDC Every Dose Every Day toolkit
Key to Acronyms: apps = applications; ARV = antiretroviral; AE = adverse effect; DOT = directly observed therapy

Download Guidelines