Pediatric Antiretroviral Therapy

Adriana Cadilla; Nadia Qureshi; Daniel C Johnson


Expert Rev Anti Infect Ther. 2010;8(12):1381-1402. 

In This Article

Abstract and Introduction


The rate of perinatal HIV transmission has decreased significantly in developed countries. However, worldwide, it remains the main source of HIV infection within the pediatric population. Recent advances as a result of findings from clinical trials, viral resistance testing and the advent of new drugs have increased the options for initial treatment regimens. This article provides an overview of antiretroviral therapy in treatment-naive children, including recent pediatric data and updated guidelines from the NIH. It also provides information on new drugs approved for the pediatric age group, dosage information, drug resistance testing and monitoring suggestions for children and adolescents receiving antiretroviral therapy. Special issues pertaining to adherence, disclosure and contraception are also highlighted.


According to the 2009 AIDS update from the Joint United Nations Program on HIV/AIDS, there are currently 2.1 million children living with HIV worldwide, with an estimated 430,000 new HIV infections among children under 15 years of age.[201] The number of newly infected children with HIV in 2008 was approximately 18% lower than in 2001. Mother-to-child transmission (MTCT) continues to account for most of these infections. Although the widespread use of antiretroviral (ARV) therapy (ART) administered during pregnancy and at the time of delivery, followed by prophylactic treatment of the exposed newborn, has reduced the rate of perinatal HIV transmission to less than 2% in developed countries,[1] under-resourced nations continue to see a high number of cases of MTCT.

In the USA, the number of annual perinatal HIV infections decreased from an estimated peak of 1650 in 1991[2] to 64 in 2007.[202] No new HIV infections secondary to MTCT were reported in the Netherlands in 2007[203] or in Switzerland in 2008.[201] A similar trend was noted in Canada, where the HIV infection rate among perinatally exposed infants fell from 22% in 1997 to 3% in 2006.[204] Sadly, an estimated 390,000 children were infected in sub-Saharan Africa in 2008.[201] There has been a tremendous improvement in access to services to prevent MTCT in Africa but it is still suboptimal. The number of HIV-infected pregnant women receiving ARV drugs to prevent transmission rose from just 9% in 2004 to 45% in 2008.[201] In 2008, almost 20% of new HIV infections in Swaziland were secondary to MTCT[205] and the figure was 15% in Uganda.[206]

Much has been learned about the disease in just three decades (Figure 1). The use of prophylactic antibiotics targeted against opportunistic infections, availability of viral resistance testing, new drug formulations with new combinations of medications aimed to reduce pill burden and decreased drug toxicities have improved the clinical outcome of HIV-infected people.

Figure 1.

Timeline of HIV, from the earliest known confirmed case of HIV in 1959 to the present.
Procleix® Ultrio® (NAT for HIV and HCV), RealTime HIV-1 assay and AmpliPrep COBAS®.
Ab: Antibody; Ag: Antigen; ARV: Antiretroviral; AZT: Zidovudine; CCR5: Chemokine receptor type 5; ddI: Didanosine; GRID: Gay-related immune deficiency; HCV: Hepatitis C virus; HTLV-III: Human T-lymphotropic virus type III; MTCT: Mother-to-child transmission; NAT: Nucleic acid test; PI: Protease inhibitor; VL: Viral load; WB: Western blot. Data from [223–225].

There was a dramatic decline in morbidity and mortality among HIV-infected adults and children directly associated with the increased use of ART.[3–6] Death rates significantly decreased between 1994 and 2000, from 7.2 to 0.8 per 100 person-years, and remained relatively stable through 2006.[7]


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