What are the current treatments for paediatric HIV and their limitations?

The 2013 WHO guidelines recommend early diagnosis, and immediate treatment of HIV positive infants and children under the age of five, regardless of immunological status; infants under the age of three should be treated with an antiretroviral treatment (ART) combination that includes protease inhibitors, regardless of whether they have been exposed to ARVs, for the prevention of mother-to-child transmission (PMTCT). The combination of a boosted protease inhibitor (PI) with two nucleoside reverse transcriptase inhibitors (NRTIs), ABC + 3TC or ZDV + 3TC, is considered by the WHO as the most effective first-line therapy for infants and children.

However, this combination therapy is not being widely used. According to a WHO survey performed in 45 countries, in 2010 only 12.2% of children with HIV were receiving a first-line treatment containing lopinavir/ritonavir (LPV/r), 97% of whom were in South Africa. The only available PI for young children, LPV/r, does not come in a child-friendly formulation: the oral solution is unpalatable, contains 42% alcohol, and is not adapted to resource-poor settings due to major logistical constraints: it requires refrigeration, has a short shelf-life when exposed to heat, is expensive, and difficult to store and transport.

 

Current treatments for paediatric HIV: testimonies of South African mothers


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In some places, the levels of co-infection with TB and HIV in infants and children are high. Drug-drug interactions between PIs in particular and rifampicin, one of the drugs used to treat TB greatly diminish the blood levels of PIs and hinder the efficacy of the antiretroviral (ARV) treatment. In order to counteract this interaction, extra ritonavir (RTV) needs to be added to the standard proportion of LPV/r. This is called ‘superboosting’. The currently available ritonavir formulation suffers the same limitations as the current formulation of RTV with regard to taste, high alcohol content, and logistical constraints imposed by its short shelf-life.