HHS Updates Treatment Guidelines for Children and Adolescents With HIV

The United States Department of Health and Human Services (HHS) Panel on Antiretroviral Therapy and Medical Management of Children Living With HIV recently released an updated set of guidelines for the use of antiretroviral drugs (ARV) in pediatric HIV infection.

Lateral HIV transmission can occur during pregnancy, child birth, and breastfeeding and, according to the US Centers for Disease Control and Prevention (CDC), 73 children under the age of 13 received a diagnosis in 2017 of perinatally acquired HIV in the United States and dependent areas, and there were 1814 children with diagnosed perinatal HIV living in the same areas at the end of 2016. On April 16, 2019, the HHS panel released its updated Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, which addresses the diagnosis of HIV in infants and children as well as the use of antiretroviral therapy (ART) in children living with HIV, including adolescents. The guideline updates are based on major revisions made within the previous 12 months.

“The care of children living with HIV is complex and evolves rapidly as results of new research are reported, new ARV drugs are approved, and new approaches to treatment are recommended,” the new guidelines state. “As additional ARV drugs are approved and optimal strategies for the use of these drugs in children become 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.”

Included in the updated text is data from an observational surveillance study conducted in Botswana on birth outcomes among pregnant women on ART, which suggest a possible increased risk of neural tube defects in infants born to women who were taking dolutegravir at the time of conception. Although investigators continue to collect data on this potential risk, the guidelines now include links to information and specific recommendations on the initiation and use of the drug dolutegravir in women of childbearing potential and in those who are pregnant.

The new guidelines also include the addition of new recommendations on when to initiate therapy in ART-naive children, with updated wording that calls for rapid initiation of treatment within 1 to 2 weeks, with an expedited discussion of adherence for children aged 6 weeks and older up to 12 weeks and for children of any age with immunodeficiency or opportunistic illnesses that indicate stage 3 HIV infection.

In addition, there are revised recommendations on which ART regimens to use as initial therapy in children to reflect the new weight parameters for use of some drugs, along with updates to recommendations for preferred versus alternative regimens. Information on drugs not recommended for children due to unacceptable toxicities, inferior virologic efficacy, high pill burdens, pharmacologic concerns, or limited pediatric data has been moved to a new section of the guidelines in Appendix A: Pediatric Antiretroviral Drug Information titled “Archived Drugs.”

With the addition of a new subsection concerning the mental health concerns of adolescents with perinatally acquired HIV, the new guidelines also include a recommendation for mental health disorder and substance use disorder screenings for adolescents living with HIV.