We have made tremendous progress in terms of reducing the risk of mother-to-child transmission. Provided that an HIV-positive woman takes good care of herself and her developing baby, which includes getting proper prenatal care and taking a combination of HIV medications during pregnancy, labor and delivery—the risk of HIV transmission is less than 2 percent. Better testing and prevention efforts since the mid-1990s have resulted in a 90% decline in the infection rate in the U.S.
Today, thanks to early access to care and advances in HIV drug treatment, being an HIV-positive child is not nearly as dire as it once was. And with more information quickly emerging with respect to how HIV-infected children should be treated, we can expect the success rate to improve significantly.
Nonetheless, caring for a child who is HIV positive comes with many challenges. HIV, even during the earliest stages of infection, can severely affect a child's development, whether related to physical growth, psychological evolvement, or emotional well-being.
Children have different immune systems than adults. HIV rapidly impairs a child's immune system ability to control common childhood infections, such as bacterial-associated lung and ear infections and viral infections like chicken pox. HIV also prevents the immune system from producing memory cells which, in adults, help ward off life-threatening infections like Pneumocystis pneumonia (PCP), Mycobacterium avium complex (MAC), and cytomegalovirus (CMV). What's more, many HIV-infected children are born to mothers who abused alcohol and/or drugs while pregnant, which can worsen problems caused by HIV infection.
Researchers have shown that HIV-infected babies tend to have higher viral loads than adults. As a result, the lessons we have learned treating adults with HIV hold true for children infected with the virus: a powerful combination of drugs should be used to lower a child's viral load to the lowest possible level.
Are HIV meds safe for children?
Many clinical trials have determined that some HIV drugs, particularly when used in combination with each other, work well and are safe in children. However, it is important to recognize that many HIV drugs are absorbed, metabolized and eliminated from the body differently in children than in adults. Fortunately, many of the drugs used to treat adults with HIV can also be used to treat children with HIV infection. In fact, many have also been found to be safe and effective for newborns and infants infected with the virus.
When should children start HIV treatment?
The United States Department of Health and Human Services (DHHS)—a branch of the federal government that oversees health care policy in the United States—has published guidelines focusing on how best to treat HIV-infected children. These guidelines are important, as they help to make sure that all HIV-infected children in the United States are sufficiently cared for and treated.
The guidelines, which were updated in March 2015, are based on data collected from a number of studies—along with expert opinions—focusing on the importance of treating HIV-positive children, including the best time to start treatment and the best treatments to use.
Here are the DHHS recommendations of when HIV treatment should be started by HIV-infected children:
Recommend Urgent Treatment
Combination Antiretroviral Therapy should be initiated urgently is all HIV-infected children with any of the following:
- Age < 12 months
- Aged 1 to < 6 years and CD4 counts are less than 500
- Aged ≥ 6 years and CD4 counts are less than 200
Combination Antiretroviral Therapy should be initiated in HIV-infected children ≥1 year with any of the following:
- Moderate HIV-related symptoms
- Viral load is > 100,000
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- Age ≥6 years and CD4 count is between 200-499
Combination Antiretroviral Therapy should be considered for HIV-infected children aged ≥1 year with:
- Mild HIV-related symptoms or are asymptomatic and
- Ages 1 to ≤6 years with a CD4 count ≥1000
- Age ≥6 years with a CD4 count ≥500
If you are caring for an HIV-positive child who is not being treated or have questions about starting your child on antiretroviral medications, be sure to discuss these issues with your child's pediatrician.
Once HIV treatment is started, the HIV-positive child will need to be monitored regularly to make sure that the medications are working well and not causing any serious side effects. If a significant problem arises while on therapy—such as a viral load becoming and/or remaining detectable, suppression of the immune system, symptoms of infection, slowed development of the central nervous system or growth failure —a switch in therapy might be necessary.
What drug combinations are recommended for children?
As is the case with adults infected with HIV, HIV-positive children almost always need to be treated with a combination of drugs to help push their viral loads to undetectable levels. This helps delay drug resistance, prolong the effects of treatment and keeps the immune system functioning properly.
Click here for the DHHS treatment guidelines for treating HIV-infected children beginning therapy for the first time (as of March 2015):
Here are the preferred and alternate regimens recommended by the DHHS for initial therapy for HIV infection in children:
a LPV/r should not be administered to neonates before a postmenstrual age (first day of the mother’s last menstrual period to birth plus the time elapsed after birth) of 42 weeks and postnatal age ³14 days.
b EFV is licensed for use in children aged ³3 months who weigh ³3.5 kg but is not recommended by the Panel as initial therapy in children aged ³3 months to 3 years. Unless adequate contraception can be ensured, EFV-based therapy is not recommended for adolescent females who are sexually active and may become pregnant.
c NVP should not be used in postpubertal girls with CD4 cell count >250/mm3, unless the benefit clearly outweighs the risk. NVP is FDA-approved for treatment of infants aged ≥15 days.
d RAL pills or chewable tablets can be used in children aged ≥2 years as an alternate INSTI. Use of granules or chewable tablets in infants and children aged 4 weeks to 2 years can be considered in special circumstances.
e DRV once daily should not be used if any of the following resistance-associated substitutions are present (V11I, V32I, L33F, I47V, I50V, I54L, I54M,T74P, L76V, I84V, and L89V).
Click here to for the full DHHS guidelines for the use of antiretrovirals for HIV-infected children.
What about opportunistic infections?
As with adults, HIV-infected children need to take preventive therapies (prophylaxis) to ward of common childhood and AIDS-related infections. It’s estimate that 20 percent of HIV-positive children will have an opportunistic infection within the first year of their life.
All children less than 1 year of age must take Bactrim or Septra (TMP-SMX)—or if they are allergic to sulfa-based drugs, either dapsone or aerosolized pentamidine (NebuPent)—to prevent Pneumocystis pneumonia (PCP). Children between the ages of 1 and 2 should take PCP prophylaxis if their CD4 cells fall below 750. Two- to five-year-olds with CD4 cell counts below 500 should also be taking prophylaxis, as should all children six years or older with CD4 counts below 200 (similar to adult recommendations).
A rather unique HIV-related problem among children is lymphoid interstitial pneumonitis (LIP). LIP is caused by a hyperactive immune response to a usually harmless infection in the lungs. The symptoms are similar to those of asthma (e.g., coughing, wheezing, shortness of breath, tightness in the chest) and, likewise, are treated with corticosteroids like prednisone, and with inhalers to ease breathing.
While research continues to show that HIV therapy has made a tremendous impact on the lives of children living with HIV, it's not yet entirely understood to what extent these powerful drugs affect young immune systems. In turn, maintaining children on treatment remains the standard of care, and it is still not clear whether or not immune system-related complications such as LIP are less likely to occur during successful HIV therapy.
The bottom line is that the care and treatment of our youngest patients with HIV has come a long, long way in recent years. While it will take some time to sort out the unique complications facing HIV-positive children, fortunately, time is one thing many HIV-positive children now have.
Last Revised: February 14, 2016