[Recommendations of the CEVIHP/SEIP/AEP/PNS on antiretroviral treatment in HIV-infected children and teenagers].
OBJECTIVE
To update antiretroviral recommendations in antiretroviral therapy (ART) in HIV-infected children and adolescents.


METHODS
Theses guidelines have been formulated by a panel of members of the Plan Nacional sobre el SIDA (PNS) and the Asociacion Espanola de Pediatria (AEP) by reviewing the current available evidence of efficacy, safety, and pharmacokinetics in pediatric studies. Three levels of evidence have been defined according to the source of data: Level A: randomized and controlled studies; Level B: Cohort and case-control studies; Level C: Descriptive studies and experts' opinion.


RESULTS
When to start ART should be made on an individual basis, discussed with the family, considering the risk of progression according to age, CD4 and viral load, the ART-related complications and adherence. The ART goal is to reach a maximum and durable viral suppression. This is not always possible, even with clinical and immunologic improvement. The difficulties of permanent adherence and side-effects are resulting in a more conservative trend to initiate ART, and to less toxic and simpler strategies. Currently, combinations of at least three drugs are of first choice both in acute and chronic infection. They must include 2 NA 1 1 NN or 2 NA 1 1 PI. ART is recommended in all symptomatic patients and, with few exceptions, in all infants in the first year of life. Older asymptomatic children should start ART according to CD4 count, especially CD4 percentage, that vary with age. Despite potent salvage therapies, it is common not to reach viral undetectability. Therapeutical options when ART fails are scarce due to cross-resistance. The cause of failure must be identified. Occasionally, there exists clinical and/or immunological progression, and a change of therapy with at least two new drugs still active for the patient, is warranted with the aim of increasing the CD4 count to a lower level of risk. Toxicity and adherence must be regularly monitored. Some aspects about post exposure prophylaxis and coinfection with HCV or HBV are discussed.


CONCLUSIONS
A higher level of evidence with regard to ART effectiveness and toxicity in pediatrics is currently available, leading to a more conservative and individualized approach. Clinical symptoms and CD4 count are the main determinants to start and change ART.
Ramos
José Tomás
JT
Unidad de Inmunodeficiencias, Departamento de Pediatría, Hospital 12 Octubre, 28041 Madrid, Spain. jramos.hdoc@salud.madrid.org
de José
María Isabel
MI
Polo
Rosa
R
Fortuny
Claudia
C
Mellado
María José
MJ
Muñoz-Fernández
María Angeles
MA
Beceiro
José
J
Bertrán
José María
JM
Calvo
Cristina
C
Chamorro
Lourdes
L
Ciria
Luis
L
Guillén
Sara
S
González-Montero
Raúl
R
González-Tomé
María Isabel
MI
Gurbindo
María Dolores
MD
Martín-Fontelos
Pablo
P
Martínez-Pérez
Jorge
J
Moreno
David
D
Muñoz-Almagro
María Carmen
MC
Mur
Antonio
A
Navarro
María Luisa
ML
Otero
Carmen
C
Rojo
Pablo
P
Rubio
Bárbara
B
Saavedra
Jesús
J
D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy*; D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods / Q000592:standards; D002648:Child; D002986:Clinical Trials as Topic; D015497:HIV-1; D006801:Humans; D013030:Spain
D019380:Anti-HIV Agents