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HIV treatment

HIV treatment can mean a longer and healthier life for children with HIV. This treatment consists of taking a combination of three different anti-HIV drugs. If these drugs are taken properly, levels of HIV in the blood reduce to very low levels as no more new virus is being produced and the HIV is ‘asleep’. This is called an undetectable viral load and is the aim of HIV treatment.

Having an undetectable viral load doesn’t mean that a person has been cured of HIV. If the treatment is stopped new virus will immediately start to be made again. However, on treatment, because there’s very little HIV in the blood, the immune system can stay strong and fight infections. This means that your child will have a good chance of staying well.

Available drugs

There are fewer anti-HIV drugs approved for treating children with HIV than there are for HIV-positive adults. Furthermore, some drugs can only be taken by children aged three and above, and the use of others is restricted to children aged six and above. However, you may find that your child is prescribed an anti-HIV drug that hasn’t been formally approved for use in children. The use of medicines in this way is guided by current medical opinion and practice.

If you have any worries about your child’s medication, always speak to his or her HIV doctor (paediatrician). Never stop giving your child his or her medication without speaking to the doctor first.

Doses

The doses of anti-HIV drugs given to children will depend on either the child’s weight or size. These will be regularly monitored by the clinic to make sure your child receives the safest and most effective doses of their treatment.

When to start HIV treatment

All babies, under one year of age, who are infected with HIV should start HIV treatment immediately. This is also the case for babies who become infected with HIV through breastfeeding.

It is also recommended that all children aged over twelve months when they are diagnosed, who are ill because of HIV, should start taking HIV treatment.

Starting treatment at the right time can help reduce the risks of your child becoming ill not only because of HIV but also with some other serious illnesses.

Therefore children aged over twelve months are recommended to start HIV treatment when their CD4 cell count falls to a certain level. The level depends on the age of the child:

Aged 1 to 3 years: CD4 cell percentage below 25%, or a CD4 cell count below 1000.

Aged 3 to 5 years: CD4 cell percentage below 20%, or a CD4 cell count below 500.

Aged 5 years and above: CD4 cell count below 350.

In making a recommendation about starting HIV treatment, your child’s doctor may also consider other factors. For example, HIV treatment may be started earlier if your child has a high viral load (above 100,000 copies/ml).

What to start HIV treatment with

The choice of drugs used to treat your child will depend on a number of factors. These include:

  • Age
  • Availability of formulations
  • Your circumstances

If the mother has developed a strain of HIV that is resistant to some anti-HIV drugs, it’s possible that this resistance may have been passed on to her child. Therefore all children should have a resistance test when decisions are being made about the most suitable combination of drugs.

A test (HLA B*5701) should also be performed to check for the possible hypersensitivity reaction to the drug abacavir (Ziagen, also in the combined pills Kivexa and Trizivir). If the HLA B*5701 test is positive then the child should not receive abacavir.

There are different types, or classes, of anti-HIV drugs. These work against HIV in different ways. To ensure that HIV treatment is successful at suppressing the virus, it is usual to take a combination of three anti-HIV drugs and these will come from at least two different classes of drugs.

The preferred first-line combination comprises two nucleoside reverse transcriptase inhibitors (NRTIs – a type of anti-HIV drug) plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (other types of anti-HIV drug).

NRTIs

Abacavir and 3TC (Kivexa) is the recommended combination of NRTIs. If your child is HLA B*5701 test positive, then AZT and 3TC (Combivir) or tenofovir and FTC (Truvada) is recommended.

NNRTIs and PIs

The NRTI drugs are combined with either an NNRTI or a protease inhibitor (PI). For children aged under three, the preferred NNRTI is nevirapine (Viramune). For children aged over three, the preferred NNRTI is efavirenz (Sustiva).

A PI is an alternative to an NNRTI. This may be a good option if your child is likely to have difficulty taking their treatment exactly as prescribed. This is because it is harder to develop resistance to PIs. PIs usually have their anti-HIV effect boosted by taking them with a small dose of a second PI called ritonavir (Norvir).

The recommended boosted protease inhibitor is Kaletra (lopinavir/ritonavir). Alternatives for children include: atazanavir (Reyataz)/ritonavir; fosamprenavir (Telzir)/ritonavir; saquinavir (Invirase)/ritonavir; and darunavir (Prezista)/ritonavir. Kaletra is the only formulation which has both drugs combined in the same tablet or liquid; for all the others the ritonavir booster must be taken separately.

Changing treatment

The aim of HIV treatment is an undetectable viral load. If your child’s viral load doesn’t fall to undetectable levels within six months of starting HIV treatment, or falls to undetectable and then increases to detectable levels in two successive tests, then his or her treatment may need to be changed. First though, it’s important to understand why the virus has become detectable again. If it’s because your child is having difficulty taking their medication, then if that can be sorted out and treatment becomes effective again the virus may go back to sleep, and become undetectable again.

Under these circumstances, if the viral load isn’t reduced to an undetectable level then your child may develop drug-resistant HIV. This can mean that it is harder to find effective anti-HIV drugs that work to control the virus in the future. A blood test called a resistance test can check for this, and identify which HIV drugs will not work any more.

The choice of the next combination of anti-HIV drugs that your child takes will need to consider the following factors:

  • Resistance to anti-HIV drugs.
  • Availability of other anti-HIV drugs.
  • Likelihood of taking the treatment properly.

Taking HIV treatment

Taking HIV treatment properly is called treatment adherence. Your child will get the most benefit from their HIV treatment if it is taken exactly as prescribed. 

This involves:

  • Taking all the doses of medication.
  • Taking all the pills in the dose.
  • Making sure that any food requirements or restrictions are observed.
  • Making sure that doses are taken at the right time – taking pills too early or too late can be as bad as not taking them at all.

Missing doses or taking doses incorrectly can mean that viral load increases. This can lead to the development of drug-resistant HIV.

It’s therefore important that you, and – as far as possible – your child, are committed to taking treatment.

The clinic will be able to give you some tips about how to give medicines to your child and how to increase the chances of him or her taking them in the right way.

Some useful methods may include:

  • Make sure you feel positive about treatment, whether it’s for you or your child. Try not to dwell on the downsides of your child being on treatment, but concentrate on the health benefits of it. If you are finding it difficult, talk over your feelings with someone at your child’s HIV clinic, or at an HIV support organisation.
  • Involve your child. For example, let your child choose the glass used for water to take with the medicines. Or keep a chart, and let your child record each dose of medicine taken, perhaps with a colourful sticker.
  • Explain to your child that the medicine is needed to keep them well, it’s not negotiable, and make sure they understand the boundaries.
  • Establish a routine. If your child takes their medicine at the same time every day, they’ll get used to doing it. Make it like cleaning their teeth, just something you do every day to keep strong and healthy for the future.
  • Praise your child after each dose is taken.
  • Teach your child how to swallow pills. The clinic will show you how to encourage and develop your child’s pill-taking technique. For example, placing the pill near the back of the tongue and then washing it down with a good mouthful of water, followed by another good mouthful, can stop it moving around the mouth, which can make people gag or feel sick.
  • Your child may need to practise taking pills for a few days or weeks before they start their HIV medication. Training them to swallow small sweets can be a useful way forward.

Make sure that you tell a member of your child’s healthcare team if he or she is having problems taking their medicines. Many of the anti-HIV drugs used to treat children are available as either pills or liquid. If your child is having problems taking pills, then it might be possible to switch to a liquid. Or it may be possible to switch to a combination that involves fewer or smaller pills. Everyone has difficulties with medications at some time or another, so don’t feel afraid to tell the clinic team how it’s going for you – they will understand. If you let them know then you can all work together to try to find another solution.

There’s more information on taking HIV treatment in the NAM booklet, Adherence & Resistance. Although this is intended for adults, a lot of the information in it is relevant to children.

HIV & children

Published January 2010

Last reviewed January 2010

Next review December 2013

Contact NAM to find out more about the scientific research and information used to produce this booklet.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.