Despite the reduction in mother to child transmission each year 100000–220000 new HIV infections still occur in children below 14 years of age globally, with only 43% accessing antiretroviral therapy. The complexities of diagnosis, linkage to care and retention are known but all children have unique therapeutic challenges. High suppression rates in adults are not mirrored in children. In low-middle-income settings only 62.5% of children are suppressed after 12 months on therapy. Unsuitable formulations and poor access to protease inhibitors (PI) are contributory. Neonates, especially if premature or low birth weight, have unique dosing requirement and adolescents particular adherence challenges. As each developmental stage requires dosing information there are considerable delays (up to 9 years) between licensing in adults and children. Dosage for commonly used drugs are still lacking in neonates and young children, i.e. abacavir is only licensed from 3 months of age and P1093, a dosing study of dolutegravir is still in progress. Lack of data and appropriate formulations prevents harmonization of adult and pediatric guidelines. Strategies to accelerate development includes modeling of dosing and adapting study design to facilitate rapid enrollment, this includes addressing tuberculosis, still a common infection. Studies to compare regimens and drug sequencing are uncommon in children, careful extrapolation of adult data for efficacy will inform pediatric practice in planning standard regimens and placing new drugs in the therapy sequence. Most children are infected with drug resistant HIV. As adult treatment programs mature, infants of mothers failing to suppress on PI are particularly vulnerable. Despite lopinavir/ritonavir (the preferred first line therapy for young children) having a high resistance threshold, children develop resistance, where resistance testing is unavailable consideration should be given to what the appropriate third line should be. Using dolutegravir as a first line regimen in mothers may compromise this drug in first line therapy in some infants. Pediatricians share excitement for long acting injectable drugs, their best use may be to prevent HIV infection in infants. Under these circumstances, resistance should be studied in order to predict its effect on initial therapy. As new drugs and drug combinations are developed tolerability and ease of use should be actively studied as should its contribution to therapy success.
CROI Conference
