What are antiretroviral therapy considerations in adolescents and young adults with HIV infection?

Updated: Mar 16, 2020
  • Author: David J Cennimo, MD, FAAP, FACP, AAHIVS; Chief Editor: Michelle R Salvaggio, MD, FACP  more...
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Answer

Answer

For postpubertal adolescents (Sexual Maturity Rating [SMR] 4 or 5), antiretroviral treatment guidelines for adults may be used; postpubertal youth who were perinatally infected may also use the adult antiretroviral treatment guidelines. [1] Special consideration may be needed in perinatally infected patients, as they are often more treatment-experienced and may have developed a significant burden of antiretroviral resistance. Newly diagnosed patients should begin a preferred regimen, when possible. Further information can be found at HIV Treatment Regimens CDC Guidelines, Adult/Adolescent.

Puberty has a direct effect on how a drug is metabolized and on the drugs' pharmacokinetic properties; therefore, dosage of medications for HIV infection should be based on the SMR (also known as Tanner staging) of puberty and not just on age alone. [3, 4]

Adolescents in early puberty (ie, SMR stages 3 and less) should be on pediatric dosing schedules found in the pediatric treatment guidelines, [5] whereas those in late puberty (ie, SMR stages 4 and 5) should follow adult dosing schedules. [1]

Adolescents who are undergoing their growth-spurt period (ie, Tanner stage 3 in females and Tanner stage 4 in males) should follow the adult dosing guidelines. They may require more frequent visits to manage dosing changes during this time.

Puberty may be delayed in children who were perinatally infected with HIV, adding to discrepancies between Tanner stage-based dosing and age-based dosing. [6]

Dosing of antiretroviral medications for adolescents can be unpredictable and is dependent on multiple factors, including body mass and composition and chronologic age. [1]

The possibility of pregnancy should be discussed with all adolescent females. Patients should be counseled on options to prevent pregnancy, as well as the potential for drug interactions with hormonal contraceptives. Guidelines for Use of Antiretroviral Agents in HIV Infected Adults and Adolescents Tables 18a, b, and d provide further information on drug interactions. [1] In general, oral contraceptives have significant interactions with protease inhibitors, efavirenz, and elvitegravir. Long-acting injectable contraception is compatible with protease inhibitors and NNRTIs, but data are limited with integrase inhibitors. Further information can be found under Gynecologic Care of Women With HIV.

In women who are planning pregnancy or are likely to become pregnant, antiretrovirals should be chosen to minimize risks to the developing fetus while still providing maximal virologic control for the patient. Recent guidelines have relaxed prohibitions on the use of efavirenz but now discourage dolutegravir in this patient group. [1] Further information can be found at HIV in Pregnancy.

Adolescents are at risk of transmitted drug resistance, and baseline genotype data should guide antiretroviral selection. [7]


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