Switch Strategies, Special Populations

Switch Strategies for virologically supressed children and adolescents
  • The general indications for switching when virologically suppressed are as for adult PLWH, see Adult Switch Strategies, but with some additional considerations for children and adolescents relating to increasing age and weight, licensing, formulation availability, vulnerability to toxicity and predicted adherence issues in adolescence
  • As children age and grow on suppressive ART, consideration should be given to simplification to robust once daily low pill burden regimens with optimal toxicity profiles and efficacy data. For example, in children aged less than 3 years commenced on liquid LPV/r, consider switching to once daily regimens when pill swallowing achieved or dispersible DTG is available
  • If “preferred” options become available for a child as they get older then a switch to this option can be considered. However, if they are fully virologically suppressed on their current regimen with no toxicity or problems with convenience or adherence it is reasonable to remain on an alternative regimen
  • Children and their carers should be involved in discussing the relative risk/benefit of switching when well and stable on an effective regimen
  • Dual therapy is not recommended in first line or for simplification but can be considered on a case by case basis in adherent children and adolescents living with HIV
  • Simplification to monotherapy and treatment interruptions are not recommended and are discouraged
Special Populations
  • Seek specialist expert advice e.g. through an MDT/PVC. If local MDT or PVC are unavailable, an international PVC is accessible by contacting the Guideline Team.
  • Adolescent girls of child bearing potential: First line options for adolescents of child bearing potential share the same considerations as discussed elsewhere in the EACS Guidelines, see Pregnancy, and should bear in mind contraceptive choices and DDIs between contraceptives and ARVs or whether the young person is trying to conceive
  • HBV co-infection: requires an ART regimen that includes TAF or TDF in the NRTI backbone typically with 3TC or FTC, see recommendation in adults with HBV/HIV co-infection
  • HCV co-infection: DAAs are licensed and available in paediatric formulations down to 3 years of age. Seek specialist advice for consideration of curative HCV therapy for children and adolescents with HCV co-infection, see recommendation in adults with HCV/HIV co-infection general recommendations and HCV treatment
  • TB co-infection: From 3 years of age, EFV, DTG bid or double dose RAL can all be considered as 3rd agents for children when co-administered with rifampicin. Under 3 years of age, EFV is not recommended, access to paediatric INSTI formulations and data on INSTI dosing are limited, super boosted LPV/r can be also be considered. Specialist advice should be sought with therapeutic drug monitoring recommended where available.
    See treatment recommendation in adults with TB/HIV co-infection