Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

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Introduction

Last Updated: April 27, 2017; Last Reviewed: April 27, 2017

These updated Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection address the use of antiretroviral therapy (ART) for infants, children, and adolescents living with HIV. In general, these guidelines are appropriate for the care and management of youth with sexual maturity rating (SMR, formerly Tanner staging) I to III, whereas the guidelines developed by the Panel for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents are suitable for the care and management of adolescents in late puberty (SMR IV-V). Guidance on management of adverse events associated with use of antiretroviral (ARV) drugs in children and a detailed review of information about safety, efficacy, and pharmacokinetics (PK) of ARV agents in children is also included. The Department of Health and Human Services (HHS) Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV (the Panel), a working group of the Office of AIDS Research Advisory Council (OARAC), reviews new data on an ongoing basis and provides regular updates to the guidelines. The Guidelines are available on the AIDSinfo website at http://aidsinfo.nih.gov.

The AIDSinfo website also includes separate guidelines for (1) the prevention and treatment of opportunistic infections (OIs) in children exposed to HIV and children with HIV infection,1 (2) the use of ARV agents in adolescents and adults with HIV,2 (3) the use of ARV drugs in pregnant women with HIV,3 and (4) the prevention and treatment of OIs in adolescents and adults with HIV.4 These guidelines are developed for the United States and may not be applicable in other countries. The World Health Organization provides guidelines for resource-limited settings at http://www.who.int/hiv/pub/arv/en.

Since the guidelines were first developed in 1993 (with the support of the François-Xavier Bagnoud Center, Rutgers, The State University of New Jersey), advances in medical management have dramatically reduced morbidity and mortality in children living with HIV in the United States. Mortality in children with perinatal HIV infection has decreased by more than 80% to 90% since the introduction of protease inhibitor-containing combinations and opportunistic and other related infections in children have significantly declined in the era of ART.5,6 ARV drug resistance testing has enhanced the ability to choose effective initial and subsequent regimens. Treatment strategies continue to focus on timely initiation of ART regimens capable of maximally suppressing viral replication in order to prevent disease progression, preserve or restore immunologic function, and prevent the development of drug resistance. At the same time, availability of new drugs and drug formulations has led to more potent regimens with lower toxicity, lower pill burden, and less frequent medication administration, all factors that can improve adherence and outcomes. The use of ARV drugs in pregnant women living with HIV has resulted in a dramatic decrease (to less than 2%) in the rate of HIV transmission to infants in the United States. In addition, children living with HIV are less likely to develop AIDS because of routine and early institution of effective ART.7,8 Finally, as a group, children living with HIV infection are growing older, bringing new challenges related to adherence, drug resistance, reproductive health planning, transition to adult medical care, and the potential for long-term complications from HIV and its treatments.9-11

The pathogenesis of HIV infection and the virologic and immunologic principles underlying the use of ART are generally similar for all individuals living with HIV, but unique considerations exist for infants, children, and adolescents living with HIV, including:

  • Acquisition of infection through perinatal exposure for most children living with HIV;
  • In utero, intrapartum, and/or postpartum neonatal exposure to ARV drugs in most children with perinatal HIV infection;
  • Requirement for use of HIV virologic tests to diagnose perinatal HIV infection in infants younger than 18 months;
  • Age-specific interpretation of CD4 T lymphocyte (CD4) cell counts;
  • Higher plasma viral loads in infants with perinatal HIV infection than in adolescents and adults with HIV infection;
  • Changes in PK parameters with age caused by the continuing development and maturation of organ systems involved in drug absorption, distribution, metabolism, and clearance; 
  • Differences in the clinical manifestations and treatment of HIV infection secondary to onset of infection in growing, immunologically immature individuals; and
  • Special considerations associated with adherence to ARV treatment in infants, children, and adolescents.

The care of children living with HIV infection is complex and evolving rapidly as results of new research are reported, new ARV drugs are approved, and new approaches to treatment are recommended. Clinical trials to define appropriate drug dosing and toxicity in children ranging in age from infancy to adolescence are critical as new drugs become available. As additional ARV drugs become approved and optimal strategies for use of these drugs in children becomes better understood, the Panel will modify these guidelines. The recommendations in these Guidelines are based on the current state of knowledge regarding the use of ARV drugs in children. Evidence is drawn primarily from published data regarding the treatment of HIV infection in infants, children, adolescents, and adults; however, when no such data are available, unpublished data and the clinical expertise of the Panel members are also considered. These guidelines are only a starting point for medical decision-making and are not meant to supersede the judgment of clinicians experienced in the care of children with HIV infection. Because of the complexity of caring for children living with HIV, and the decreasing number of children with perinatally acquired HIV in the United States, health care providers with limited experience in the care of these patients should consult with a pediatric HIV specialist.

Guidelines Development Process

An outline of the composition of the Panel and the guidelines process can be found in Table 1.

Table 1. Outline of the Guidelines Development Process
Topic Comment
Goal of the Guidelines Provide guidance to HIV care practitioners on the optimal use of ARV agents in infants, children, and adolescents (through mid-puberty) living with HIV in the United States.
Panel Members The Panel is composed of approximately 32 voting members who have expertise in management of HIV infection in infants, children, and adolescents. Members include representatives from the Committee on Pediatric AIDS of the American Academy of Pediatrics and community representatives with knowledge of pediatric HIV infection. The Panel also includes at least one representative from each of the following HHS agencies: Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH). A representative from the Canadian Pediatric AIDS Research Group participates as a nonvoting, ex officio member of the Panel. The US government representatives are appointed by their respective agencies; nongovernmental members are selected after an open announcement to call for nominations. Each member serves on the Panel for a 3-year term with an option for reappointment. A list of current members can be found in the Panel Roster.
Financial Disclosure All members of the Panel submit a financial disclosure statement in writing annually, reporting any association with manufacturers of ARV drugs or diagnostics used for management of HIV infections. A list of the latest disclosures is available on the AIDSinfo website (http://aidsinfo.nih.gov).
Users of the Guidelines Providers of care to infants, children, and adolescents living with HIV in the United States
Developer Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV—a working group of OARAC
Funding Source Office of AIDS Research, NIH and HRSA
Evidence Collection A standardized review of recent relevant literature related to each section of the guidelines is performed by a technical assistance consultant (through funding from HRSA) and provided to individual Panel section working groups. The recommendations are generally based on studies published in peer-reviewed journals. On some occasions, particularly when new information may affect patient safety, unpublished data presented at major conferences or prepared by the FDA and/or manufacturers as warnings to the public may be used as evidence to revise the guidelines.
Recommendation Grading Described in Table 2.
Method of Synthesizing Data Each section of the guidelines is assigned to a small group of Panel members with expertise in the area of interest. The members synthesize the available data and propose recommendations to the Panel. The Panel discusses all proposals during monthly teleconferences. Proposals are modified based on Panel discussion and then distributed with ballots to all Panel members for concurrence and additional comments. If there are substantive comments or votes against approval, the recommended changes and areas of disagreement are brought back to the full Panel (by email or teleconference) for additional review, discussion, and further modification to reach a final version acceptable to all Panel members. The recommendations in these final versions represent endorsement from a consensus of members and are included in the guidelines as official Panel recommendations.
Other Guidelines These guidelines focus on infants, children, and adolescents in early puberty (SMR I-III) living with HIV. Guidance for treatment for adolescents in late puberty (SMR IV-V) is provided by the Panel on Antiretroviral Guidelines for Adults and Adolescents

Separate guidelines outline the use of ART in pregnant women with HIV infection and interventions for prevention of perinatal transmission, ART for nonpregnant adults and postpubertal adolescents with HIV infection, and ARV prophylaxis for those who experience occupational or nonoccupational exposure to HIV. These guidelines are also available on the AIDSinfo website (http://www.aidsinfo.nih.gov).
Update Plan The full Panel meets monthly by teleconference to review data that may warrant modification of the guidelines. Smaller working groups of Panel members hold additional teleconferences to review individual drug sections or other specific topics (e.g., What to Start). Updates may be prompted by new drug approvals (or new indications, formulations, or frequency of dosing), new significant safety or efficacy data, or other information that may have a significant impact on the clinical care of patients. In the event of significant new data that may affect patient safety, the Panel may issue a warning announcement and post accompanying recommendations on the AIDSinfo website until the guidelines can be updated with appropriate changes. All sections of the guidelines will be reviewed, with updates as appropriate, at least once yearly.
Public Comments A 2-week public comment period follows release of the updated guidelines on the AIDSinfo website. The Panel reviews comments received to determine whether additional revisions to the guidelines are indicated. The public may also submit comments to the Panel at any time at contactus@aidsinfo.nih.gov.

Basis for Recommendations

Recommendations in these guidelines are based upon scientific evidence and expert opinion. Each recommendation includes a letter (A, B, or C) that represents the strength of the recommendation and a Roman numeral (I, II, or III) that represents the quality of the evidence that supports the recommendation.

Because licensure of drugs in children often is based on extrapolation of efficacy data from adult trials in addition to safety and PK data from studies in children, recommendations for ARV drugs often rely, in part, on data from clinical trials or studies in adults. Pediatric drug approval may be based on evidence from adequate and well-controlled investigations in adults if:

  1. The course of the disease and the effects of the drug in the pediatric and adult populations are expected to be similar enough to permit extrapolation of adult efficacy data to pediatric patients;
  2. Supplemental data exist on PKs of the drug in children indicating that systemic exposure in adults and children are similar; and
  3. Studies are provided that support the safety of the drug in pediatric patients.12-14

Studies relating drug activity to drug levels (pharmacodynamic data) in children also should be available if there is a concern that concentration-response relationships might be different in children. In many cases, evidence related to use of ARV drugs is substantially greater from adult studies (especially randomized clinical trials) than from pediatric studies. Therefore, for pediatric recommendations, the following rationale has been used when the quality of evidence from pediatric studies is limited:

Quality of Evidence Rating I—Randomized Clinical Trial Data

  • Quality of Evidence Rating I will be used if there are data from large randomized trials in children with clinical and/or validated laboratory endpoints.
  • Quality of Evidence Rating I* will be used if there are high-quality randomized clinical trial data in adults with clinical and/or validated laboratory endpoints and pediatric data from well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes that are consistent with the adult studies. A rating of I* may be used for quality of evidence if, for example, a randomized Phase III clinical trial in adults demonstrates a drug is effective in ARV-naive patients and data from a nonrandomized pediatric trial demonstrate adequate and consistent safety and PK data in the pediatric population.
Quality of Evidence Rating II—Nonrandomized Clinical Trials or Observational Cohort Data
  • Quality of Evidence Rating II will be used if there are data from well-designed nonrandomized trials or observational cohorts in children.
  • Quality of Evidence Rating II* will be used if there are well-designed nonrandomized trials or observational cohort studies in adults with supporting and consistent information from smaller nonrandomized trials or cohort studies with clinical outcome data in children. A rating of II* may be used for quality of evidence if, for example, a large observational study in adults demonstrates clinical benefit to initiating treatment at a certain CD4 cell count and data from smaller observational studies in children indicate that a similar CD4 cell count is associated with clinical benefit.

Quality of Evidence Rating III—Expert opinion

  • The criteria do not differ for adults and children.

In an effort to increase the amount and improve the quality of evidence available for guiding management of HIV infection in children, the discussion of available trials with children and their caregivers is encouraged. Information about clinical trials for adults and children with HIV infection can be obtained from the AIDSinfo website (https://aidsinfo.nih.gov/Clinical-Trials/) or by telephone at 1-800-448-0440.

Table 2. Rating Scheme for Recommendations
Strength of Recommendation Quality of Evidence for Recommendation
A: Strong recommendation for the statement

B: Moderate recommendation for the statement

C: Optional recommendation for the statement
I:  One or more randomized trials in childrena with clinical outcomes and/or validated laboratory endpoints

I*: One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints plus accompanying data in childrena 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 childrena with long-term clinical outcomes

II*: One or more well-designed, nonrandomized trials or observational cohort studies in adults with long-term clinical outcomes plus accompanying data in childrena from one or more smaller nonrandomized trials or cohort studies with clinical outcome data

III: Expert opinion
a Studies that include children or children and adolescents but not studies limited to post-pubertal adolescents

References

  1. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2016. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf. Accessed January 25, 2017
  2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2016. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed January 25, 2017.
  3. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. 2016. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed January 25, 2017.
  4. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2016. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed January 25, 2017.
  5. Kapogiannis BG, Soe MM, Nesheim SR, et al. Mortality trends in the US Perinatal AIDS Collaborative Transmission Study (1986–2004). Clin Infect Dis. 2011;53(10):1024-1034. Available at http://www.ncbi.nlm.nih.gov/pubmed/22002982.
  6. Mirani G, Williams PL, Chernoff M, et al. Changing trends in complications and mortality rates among US youth and young adults with HIV infection in the era of combination antiretroviral therapy. Clin Infect Dis. 2015;61(12):1850-1861. Available at http://www.ncbi.nlm.nih.gov/pubmed/26270680.
  7. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics. 2012;130(4):738-744. Available at http://www.ncbi.nlm.nih.gov/pubmed/22945404.
  8. Centers for Disease Control and Prevention. Revised surveillance case definition for HIV infection—United States, 2014. MMWR Recomm Rep. 2014;63(RR-03):1-10. Available at http://www.ncbi.nlm.nih.gov/pubmed/24717910.
  9. Committee On Pediatric AIDS. Transitioning HIV-infected youth into adult health care. Pediatrics. 2013;132(1):192-197. Available at http://www.ncbi.nlm.nih.gov/pubmed/23796739.
  10. Cervia JS. Addressing the needs of youth with HIV infection in the era of combination antiretroviral therapy. Clin Infect Dis. 2016;62(7):947. Available at http://www.ncbi.nlm.nih.gov/pubmed/26743091.
  11. de Martino M, Galli L, Chiappini E. Perinatal human immunodeficiency virus type-1 in the 21st century: new challenges in treatment and health care organization. Pediatr Infect Dis J. 2015;34(5 Suppl 1):S1-2. Available at http://www.ncbi.nlm.nih.gov/pubmed/25894972.
  12. Food and Drug Administration. Guidance for Industry: General considerations for pediatric pharmacokinetic studies for drugs and biological products. November 30, 1998. http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm072114.pdf 
  13. Dunne J, Rodriguez WJ, Murphy MD, et al. Extrapolation of adult data and other data in pediatric drug-development programs. Pediatrics. 2011;128(5):e1242-1249. Available at http://www.ncbi.nlm.nih.gov/pubmed/22025597.
  14. Murphy D. Extrapolation of efficacy in the pediatric population. Food and Drug Administration. 2012. Available at http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/PediatricTherapeuticsResearch/UCM340587.pdf. January 25, 2017.

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