7.2.3 First-line ART for children younger than three years of age
Consolidated ARV guidelines, June 2013
Optimizing first-line ART in children younger than three years is critical to achieving effective and rapid control of viral replication in the context of high viral load and rapid infant growth. Considerations that may require alternative therapeutic approaches include the limited availability of drugs in appropriate formulations, the long-term toxicities of ARV drugs, difficulty with adherence and the possibility of pre-existing viral resistance because of ARV drug exposure for PMTCT.
Young children with HIV who are exposed to NNRTIs used for PMTCT have demonstrable viral resistance (150), which compromises the response to NVP-containing first-line ART (151,152). For this reason, the 2010 WHO guidelines (105) recommended the use of LPV/r-based treatment in children younger than 24 months of age previously exposed to NNRTIs. For young children not exposed to NNRTIs or whose status was unknown, an NVP-based regimen was recommended (105).
New evidence has become available for this age group suggesting the superiority of a LPV/r-based regimen regardless of PMTCT exposure (153,154). Several strategies have also been tested to overcome the challenges of using LPV/r-based regimens or to provide potent alternatives in settings in which using LPV/r is not feasible or is problematic because of the high prevalence of TB. (Web Annex)