Children living with HIV who have CD4 cell counts below 500 and are not yet receiving antiretroviral (ARV) therapy should be started on treatment, according to revised guidelines released by the U.S. Department of Health and Human Services (DHHS) on August 11. Other revisions, which update a previous version published in August 2010, include updated treatment options for HIV-positive children beginning therapy for the first time.

Since the pediatric HIV/AIDS treatment guidelines were first developed in 1993, dramatic advances in medical management have been documented. Death rates among children living with the virus in the United States have decreased by more than 80 percent to 90 percent since the introduction of ARV drug combinations. Other advances, including resistance testing and the ability to measure ARV drug levels, have enabled health care providers to more carefully choose very effective initial regimens while preserving selected drugs and drug classes for second- or third-line regimens.

Much like in adults living with HIV, pediatric therapeutic strategies continue to focus on early initiation of ARV regimens capable of maximally suppressing viral replication to prevent disease progression, preserve immunologic function and reduce the development of resistance. At the same time, availability of new drugs and drug formulations has led to regimens with less frequent dosing schedules that improve adherence. Improved monitoring and dosing schedules have also led to a decrease in drug failure due to toxicity.

Meanwhile, the widespread use of ARV treatment during pregnancy has resulted in a dramatic decrease in the transmission rate to infants, which is currently less than 2 percent in the United States and thus means fewer children are being born with HIV. Challenges, however, remain. Those less fortunate children still require state-of-the-art care. Children living with HIV are, as a group, growing older, bringing new challenges of adherence, drug resistance, reproductive health planning, management of multiple drugs, and long-term complications from HIV and its treatments.

In an effort to stay ahead of these challenges, the DHHS remains committed to interpreting pediatric research data in order to maintain best practices for providers caring for children living with HIV.

According to the most recent Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, children age 5 and older who are living with HIV and do not have symptoms but do have CD4 cell counts below 500 should be started on treatment, similar to the recommendation for adults. The previous version of the guidelines recommended treatment for asymptomatic children older than 5 once their CD4s fall below 250.

Kaletra (lopinavir/ritonavir), combined with two nucleoside reverse transcriptase inhibitors (NRTIs), is the preferred ARV regimen for children between 2 weeks and 3 years old. Viramune (nevirapine) combined with two NRTIs is considered the alternative option in this very young population.

For several years, Kaletra has also been a preferred protease inhibitor option for children living with HIV who are 6 years old or older. It is now joined by Norvir (ritonavir)–boosted Reyataz as a preferred option for this age bracket.

Preferred NRTI combinations are also revised in the new guidelines. In addition, new sections highlight the latest research on nervous system problems, gastrointestinal side effects and kidney toxicity, as they relate to the use of ARVs in children.

As the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection is a living document, its authors are soliciting feedback through August 30, 2011. Questions, comments or concerns can be submitted by email.