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New Treatment Guidelines for HIV-Positive Children
by Tim Horn
October 31, 2006 (AIDSmeds.com)—The U.S. Department of Health and Human Services (DHHS) has completely revised its treatment guidelines for HIV-positive children. The October 26 edition of the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection contains significant changes to its recommendations regarding when to begin therapy and which agents to use, along with a major overhaul of the discussion sections to improve their organization and readability.
Since the pediatric guidelines were first developed in 1993, there have been a number of dramatic advances in the treatment of HIV-positive children. AIDS-related deaths have dropped by 70% since the introduction of combination HIV treatment, and opportunistic infections have also significantly decreased in HIV-positive children with access to antiretroviral therapy. What’s more, advances from clinical trials and studies exploring laboratory monitoring – such as drug-resistance testing and therapeutic drug monitoring – have enabled physicians to more carefully choose very effective first-time treatment regimens while preserving other important drugs for subsequent regimens.
Treating HIV-positive children is not without its challenges. While fewer children are being diagnosed with HIV today, thanks to highly successful preventive treatment during pregnancy, there are still a sizable number of HIV-positive children in the United States. As a group, these children are growing older, bringing new challenges of dosing, adherence, drug resistance, and management of multiple drugs.
Much like the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (last updated October 10, 2006), the experts responsible for maintaining the pediatric guidelines meet regularly to discuss changes that are necessary to meet the treatment needs and challenges of HIV-positive children and their healthcare providers.
The October 26 version of the pediatric guidelines involves a major rewrite of previous editions. Much of the rewrite, the authors say, was intended to make the document more accessible to clinicians and to help better organize the information.
The revised pediatric guidelines can be accessed at: http://aidsinfo.nih.gov/ContentFiles/PediatricGuidelines.pdf
One of the most significant changes, with respect to recommendations, involves the initiation of treatment in HIV-positive children. Deciding when to begin treatment, the panelists say, greatly depends on the age of the child. There are now specific recommendations for children under 12 months of age, between one and four years of age, four to 12 years of age, and 13 years of age and older. ( See Table 6 on page 57 of the revised guidelines for more information.)
The October pediatric guidelines also contain revisions to a table highlighting the preferred medications choices for HIV-positive children starting therapy for the first time (see Table 7 on page 58). For example, Sustiva® (efavirenz) plus two nucleoside reverse transcriptase inhibitors (NRTIs) is the preferred non-nucleoside reverse transcriptase inhibitor (NNRTI)-based option for children three years of age or older. For those younger than three years of age, or those unable to swallow pills, the pediatric formulation of Viramune® (nevirapine) is the preferred NNRTI choice. As for protease inhibitors, Kaletra® (lopinavir plus ritonavir) remains the preferred choice.
Also of note are revised recommendations for adolescents, including issues related to dosing, use of birth control, pregnancy, and transition into adult care.
