What's New in the Pediatric Guidelines

Updated Reviewed Jan. 31, 2023

January 31, 2023

The Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV (the Panel) has reviewed and updated the sections of the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection that are developed in collaboration with the Panel on Treatment of HIV in Pregnancy and Prevention of Perinatal Transmission. These changes are highlighted in yellow in the PDF version of the guidelines.

Maternal HIV Testing and Identification of Perinatal HIV Exposure

  • This section was revised for clarification and to provide explanatory content about HIV testing, including expedited HIV tests, during pregnancy and postpartum. Subsections were added on approved HIV tests and testing algorithms and false positive HIV tests.

Infant Feeding for Individuals with HIV in the United States

  • Updated recommendations for infant feeding are now included as a shared section in the Perinatal Guidelines.
  • The Panel recommends that people with HIV receive evidence-based, patient-centered counseling to support shared decision-making about infant feeding. Counseling about infant feeding should begin prior to conception or as early as possible in pregnancy; information about and plans for infant feeding should be reviewed throughout pregnancy and again after delivery (AIII). During counseling, people should be informed that—
    • Replacement feeding with properly prepared formula or pasteurized donor human milk from a milk bank eliminates the risk of postnatal HIV transmission to the infant (AI).
    • Achieving and maintaining viral suppression through antiretroviral (ARV) therapy during pregnancy and postpartum decreases breastfeeding transmission risk to less than 1%, but not zero (AI).
  • Replacement feeding with formula or banked pasteurized donor human milk is recommended to eliminate the risk of HIV transmission through breastfeeding when people with HIV are not on antiretroviral therapy (ART) and/or do not have a suppressed viral load during pregnancy (at a minimum throughout the third trimester) and at delivery (AI).
  • Individuals with HIV who are on ART with a sustained undetectable viral load and who choose to breastfeed should be supported in this decision (AIII).
  • Individuals with HIV who choose to formula feed should be supported in this decision; potential barriers to formula feeding should be identified and addressed (AIII).
  • Content about counseling and management of individuals who choose to breastfeed was updated, with added content on situations in which to consider stopping or modifying breastfeeding.

Diagnosis of HIV Infection in Infants and Children

  • This section now provides additional guidance about HIV diagnostic testing for infants with perinatal HIV exposure who are being breastfed, with time points for testing listed in Table 3. Recommended Virologic Testing Schedules for Infants Who Were Exposed to HIV According to Risk of Perinatal HIV Acquisition at and After Birth.
  • A subsection was added with information about HIV testing for infants who were being breastfed at the time of maternal HIV diagnosis.

Antiretroviral Management of Newborns with Perinatal HIV Exposure or HIV Infection

  • When the criteria for low risk of perinatal HIV transmission are met, the Panel now recommends that infants receive 2 weeks of zidovudine (ZDV) prophylaxis (BII), rather than 4 weeks (see Table 11. Neonatal Antiretroviral Management According to Risk of HIV Infection in the Newborn).
    • The criterion for viral suppression was further defined as at least two consecutive tests with HIV RNA levels <50 copies/mL obtained at least 4 weeks apart.
  • Infants born to individuals who do not meet criteria for low risk for perinatal HIV transmission but who have a viral load <50 copies/mL at or after 36 weeks should receive ZDV for 4 to 6 weeks (BII).
  • The Panel clarified the duration of ARVs for newborns at high risk of perinatal acquisition. Presumptive HIV therapy with three-drug regimens should be administered from birth for 2 to 6 weeks (see Tables 11 and 12); if the duration of the three-drug regimen is shorter than 6 weeks, ZDV should be continued alone to complete a total of 6 weeks of prophylaxis.
  • All premature infants <37 weeks gestation who are not at high risk of perinatal acquisition of HIV should receive ZDV for 4 to 6 weeks (BII).
  • New subsections and Table A. Infant Antiretroviral Prophylaxis for Newborns of Mothers with Sustained Viral Suppression Who Breastfeed were added to address ARV prophylaxis for newborns at low risk of perinatal HIV transmission who are breastfed and to provide information about breastfeeding in newborns at high risk of perinatal HIV acquisition.

October 11, 2022

The Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV (the Panel) has made revisions in the following sections of the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection to address U.S. Food and Drug Administration approval of the dispersible tablet formulation of the fixed-dose combination abacavir/dolutegravir/lamivudine (Triumeq PD) for use in children weighing 10 kg to 25 kg and the long-acting injectable cabotegravir and rilpivirine (Cabenuva) for use in children and adolescents aged ≥12 years and weighing ≥35 kg.

April 11, 2022

The U.S. Food and Drug Administration (FDA) recently approved long-acting injectable cabotegravir and rilpivirine (Cabenuva) for use in children and adolescents aged ≥12 years and weighing ≥35 kg. This change has been incorporated in the Cabotegravir and Rilpivirine drug sections; other sections have not been updated yet. The Panel has not made revisions to address the recent FDA approval of the dispersible table formulation of the fixed-dose combination (FDC) of abacavir/dolutegravir/lamivudine (Triumeq PD) for use in children weighing 10 kg to 25 kg; this will be addressed in a future update.

Clinical and Laboratory Monitoring of Pediatric HIV Infection

  • Some updates were made for clarification and to align content in bulleted recommendations, text, and Table 5. Sample Schedule for Clinical and Laboratory Monitoring of Children Before and After Initiation of Antiretroviral Therapy.
  • Some experts would consider monitoring HgbA1C in children at risk for prediabetes/diabetes, rather than routine blood glucose.
  • The Panel added a statement to point out that periodic measurements of body weight—important for dose modification in the rapidly growing infant and to monitor for excessive weight gain as a possible adverse effect of some antiretroviral (ARV) drugs—are not possible with telemedicine visits.
  • The Panel also noted that children with HIV who are relocating from outside the United States may benefit from thyroid function studies and additional evaluations, such as screening for tuberculosis, gastrointestinal parasites, hepatitis infection, and lead level.

What to Start: Regimens Recommended for Initial Therapy of Antiretroviral-Naive Children

  • The Panel has updated its recommendations for several drugs following recent FDA approvals of new pediatric dosing strength formulations for bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF, Biktarvy) and emtricitabine/tenofovir alafenamide (FTC/TAF, Descovy) and the approval of doravirine (DOR) and doravirine/emtricitabine/tenofovir disoproxil fumarate (DOR/FTC/TDF, Delstrigo) for pediatric use.
    • The Panel now recommends BIC/FTC/TAF as a Preferred integrase strand transfer inhibitor (INSTI)–based regimen for children aged ≥2 years and weighing ≥14 kg (AI*). Previously, this regimen was limited to use in children aged ≥6 years and weighing ≥25 kg.
    • DOR plus a two-nucleoside reverse transcriptase inhibitor (NRTI) backbone is now recommended as an Alternative non-nucleoside reverse transcriptase inhibitor (NNRTI)–based regimen for children and adolescents weighing ≥35 kg (BI*). The Panel’s recommendation is supported by data from studies that evaluated the efficacy and tolerability of this drug in adults, as well as early findings from pediatric pharmacokinetic (PK) studies. DOR is also available in a FDC tablet as DOR/FTC/TDF (Delstrigo).
    • FTC/TAF (Descovy) is recommended as a Preferred dual-NRTI combination in children and adolescents weighing ≥14 kg when used with an INSTI or NNRTI. Use of Descovy with an INSTI or NNRTI was previously limited to children weighing ≥25 kg.
  • The Panel recommends abacavir (ABC) plus lamivudine (3TC) or FTC as a Preferred dual-NRTI combination in children aged ≥3 months (AI) and now recommends it from birth in full-term infants aged <3 months (BIII). A negative test for the HLA-B5701 allele should be obtained before starting ABC, regardless of age. Previously, the Panel recommended ABC for infants aged ≥1 month. The Panel changed its recommendation based on PK modeling of neonatal ABC dosing to target adult plasma ABC exposures and on observational data supporting safety of ABC in full-term neonates aged <1 month. An ABC dosing recommendation based on PK simulation models has been endorsed by the World Health Organization using weight-band dosing for full-term infants from birth to 1 month of age. The FDA has approved ABC for use in children aged ≥3 months.

What Not to Start: Regimens Not Recommended for Use in Antiretroviral-Naive Children

  • The section text and Table 9. Antiretroviral Regimens or Components That Are Not Recommended for Initial Treatment of HIV Infection in Children and Adolescents have been updated to include two-drug ARV regimens, as well as three drugs that are not FDA approved for use in ARV-naive children or adults: cabotegravir, fostemsavir, and ibalizumab.
  • Any ARV regimen containing both TDF and TAF has been added to Table 10. Antiretroviral Regimens or Components That Are Never Recommended for Treating HIV in Children and Adolescents.

Special Considerations for Antiretroviral Therapy Use in Adolescents with HIV

  • This section has been updated to include additional content about substance use concerns in adolescents.

Adherence to Antiretroviral Therapy in Children and Adolescents with HIV

  • This section has been revised to provide recent data about the following adherence interventions: smartphone-based reminders, peer support interventions, modified directly administered ARV therapy, and a multicomponent intervention—including remote coaching, electronic dose monitoring, and tailored outreach.

Management of Medication Toxicity or Intolerance

Management of Children Receiving Antiretroviral Therapy

Appendix A: Pediatric Antiretroviral Drug Information

Drug sections and FDC Table 1 and Table 2 in this appendix were reviewed and updated to include recent pediatric data and dosing and safety information, plus FDA approvals of new formulations and FDCs. Significant changes are summarized below:

  • Although ABC is not approved by the FDA for use in infants aged <3 months, the Abacavir section has been updated to include a dosing recommendation for full-term infants aged <1 month. The Panel’s recommendation is based on data from PK modeling of neonatal ABC dosing to target adult plasma ABC exposures and on observational data supporting safety of ABC in full-term neonates aged <1 month. The Panel has also revised its previous dosing recommendation for full-term infants aged ≥1 month to <3 months based on modeling data provided by the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1106 study and two observational cohorts.
  • The Bictegravir, Emtricitabine, and Tenofovir Alafenamide sections have been updated to incorporate FDA approval of a new pediatric dosing strength for Biktarvy (BIC 30 mg/FTC 120 mg/TAF 15 mg) for use in children aged ≥2 years and weighing ≥14 kg to <25 kg.
  • The Emtricitabine and Tenofovir Alafenamide sections have been updated to incorporate FDA approval of a new pediatric dosing strength for Descovy (FTC 120 mg/TAF 15 mg) for use in children weighing ≥14 kg to <25 kg.
  • The Doravirine, Lamivudine, and Tenofovir Disoproxil Fumarate sections have been updated following the FDA approval of DOR and the FDC tablet DOR/3TC/TDF (Delstrigo) for use in children and adolescents weighing ≥35 kg who are ARV-naive or have been virologically suppressed (HIV RNA <50 copies/mL) on a stable ARV regimen with no history of treatment failure and no known mutations associated with resistance to DOR or to the individual components of Delstrigo.
  • The Cabotegravir and Rilpivirine sections have been revised to incorporate the FDA approval of the long-acting injectable regimen, Cabenuva (co-packaged cabotegravir [CAB] and rilpivirine [RPV] suspensions), for treatment of HIV in children and adolescents aged ≥12 years and weighing ≥35 kg with HIV RNA levels <50 copies/mL on a stable ARV regimen, no history of treatment failure, and no known or suspected resistance to CAB or RPV. The FDA has also approved the oral formulation of CAB (Vocabria) for this group of children and adolescents. Oral lead-in dosing of CAB and RPV is now an option, rather than a requirement, when starting Cabenuva; patients may proceed to Cabenuva directly from their current ARV regimen.
  • In the Efavirenz (EFV) section, the Panel has added a recommendation to measure vitamin D in children receiving EFV and to prescribe vitamin D supplementation for those with vitamin D deficiency (see Table 15j. Osteopenia and Osteoporosis for additional information). This recommendation is based on studies in adults showing that use of EFV is associated with low vitamin D levels, as well as studies that have found an association between EFV use and low bone mineral density.
  • Some text was removed from the Lopinavir/Ritonavir (LPV/r) section to clarify that the Panel does not endorse use of LPV/r in neonates before a postmenstrual age of 42 weeks and a postnatal age of at least 14 days due to the risk of metabolic and cardiac toxicity.
  • The Panel has revised the Nevirapine (NVP) section to include dosing recommendations for preterm infants at a gestational age of 32 weeks to <34 weeks based on review of PK modeling and simulation data. This dosing strategy has not been evaluated in clinical trials and is not approved by the FDA. Previously, the Panel’s dosing recommendations for preterm infants were limited to a gestational age of 34 weeks to <37 weeks.

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