Sequencing paediatric antiretroviral therapy in the context of a public health approach

• Published in: Journal of the International AIDS Society 2015-12, Vol.18 (Suppl 6), p.20265-n/a
• Main Authors: Boerma, Ragna S, Boender, T Sonia, van Hensbroek, Michael Boele, Rinke de Wit, Tobias F, Sigaloff, Kim CE
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Age; AIDS; AIDS/HIV; Anti-HIV Agents - therapeutic use; Antiretroviral agents; Antiretroviral drugs; antiretroviral therapy; Child; Clinical trials; DNA polymerases; Drug dosages; Drug resistance; Drug therapy; FDA approval; Generic drugs; Getting to 90-90-90 in paediatric HIV: What is needed?; Highly active antiretroviral therapy; HIV; HIV drug resistance; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; low‐ and middle‐income countries; Mutation; non‐nucleoside reverse transcriptase inhibitor; paediatric HIV; Pediatrics; protease inhibitor; Protease inhibitors; Proteinase inhibitors; Public Health; Reverse Transcriptase Inhibitors - therapeutic use; Systematic review
• ISSN: 1758-2652; 1758-2652
• DOI: 10.7448/IAS.18.7.20265

Introduction As access to prevention of mother‐to‐child transmission (PMTCT) efforts has increased, the total number of children being born with HIV has significantly decreased. However, those children who do become infected after PMTCT failure are at particular risk of HIV drug resistance, selected by exposure to maternal or paediatric antiretroviral drugs used before, during or after birth. As a consequence, the response to antiretroviral therapy (ART) in these children may be compromised, particularly when non‐nucleoside reverse transcriptase inhibitors (NNRTIs) are used as part of the first‐line regimen. We review evidence guiding choices of first‐ and second‐line ART. Discussion Children generally respond relatively well to ART. Clinical trials show the superiority of protease inhibitor (PI)‐ over NNRTI‐based treatment in young children, but observational reports of NNRTI‐containing regimens are usually favourable as well. This is reassuring as national guidelines often still recommend the use of NNRTI‐based treatment for PMTCT‐unexposed young children, due to the higher costs of PIs. After failure of NNRTI‐based, first‐line treatment, the rate of acquired drug resistance is high, but HIV may well be suppressed by PIs in second‐line ART. By contrast, there are currently no adequate alternatives in resource‐limited settings (RLS) for children failing either first‐ or second‐line, PI‐containing regimens. Conclusions Affordable salvage treatment options for children in RLS are urgently needed.