Antiretroviral therapy in children with HIV AIDS

The highest mortality rate for HIV-infected infants is due to the rapid progression of HIV infection in infants <1 year of age. Infants infected with perinatal HIV will mostly die before the age of 2 years, but the risk of death begins to decline at the age of > 5 years.

Indications for starting antiretroviral therapy in children < 10 years.

Several studies have shown that early initiation of antiretroviral therapy in children can reduce mortality by up to 75%.

Antiretroviral therapy should be given to all HIV-infected children regardless of clinical stage and immunosuppressed status :

• HIV-infected children diagnosed before 1 year of age.
• HIV-infected children aged > 1-10 years.

Antiretroviral therapy in children.

Antiretroviral therapy in children is divided into :

1. Age < 3 years.
2. Age 3-10 years.

The pathogenesis of perinatal HIV infection is different from that in adults. The viral load-set point in perinatally infected infants can be many times higher, therefore optimization of antiretroviral therapy in children < 3 years of age plays an important role in achieving effective control of viral replication.

First-line antiretroviral therapy in children < 3 years :

• 2 Nucleoside reverse transcriptase inhibitors + 1 Protease inhibitors (Optional) ➡️ (Abacavir/ABC or Zidovudine/AZT) + 3 Lamivudine/TC + Lopinavir/Ritonavir LPV/r
• 2 Nucleoside reverse transcriptase inhibitors + 1 Non - nucleoside reverse transcriptase inhibitors (Alternative) ➡️ (ABC or AZT) + 3TC + Nevirapine/NVP

Note : if viral load monitoring is available, a guideline for LPV/r to Efavirenz/EFV may be considered after > 3 years of age (persistent viral suppression is achieved).

Antiretroviral therapy in children 3-10 years :

• (Optional) ➡️ AZT + 3TC + EFV
• (Alternative) ➡️ 

ABC + 3TC + NVP

ABC + 3TC + EFV

AZT + 3TC + NVP

TDF + 3TC (or Emtricitabine/FTC) + EFV

TDF + 3TC (or FTC) + NVP

Prevention of mother to child transmission of HIV.

Vertical transmission is a method of transmission from mother to child through one of the processes : during intrauterine, intrapartum, or post-natal (during breastfeeding). This transmission is the main transmission (92%) of HIV infection in children aged < 13 years.

• All pregnant women with HIV should be given antiretroviral therapy without waiting for a CD4 count.
• Elective cesarean section at 39 gestational age in a pregnant HIV patient with a viral load greater than 1000 copies/ml or an unknown viral load in the third trimester.
• Infants born to HIV-infected mothers receiving breast milk ️ Zidovudine and Nevirapine prophylaxis according to gestational age for 6 weeks (mother should be on combination antiretroviral therapy).
• Babies born to HIV-infected mothers who receive breast milk substitutes ️ Zidovudine prophylaxis according to gestational age for 6 weeks.