pediatric hiv treatment guidelines update

Pediatric HIV Treatment Guidelines Update

Ana M. Puga, MD

Comprehensive Family AIDS Program

Children’s Diagnostic & Treatment Center

Fort Lauderdale, FL

Faculty, Florida/Caribbean AETC

Disclosures of Financial Relationships

This speaker has the following significant financial relationships with commercial entities to disclose:•Speaker’s Bureau: Abbott, Boehringer-Ingelheim, Gilead

This speaker will discuss off-label use or investigational product during the program:•Unlabeled use of drugs in pediatrics if pertinent to discussion for all ARVs

This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

• August 16, 2010 guidelines updated August 11, 2011

• For full set of guidelines, visit the AIDSinfo website at http://aidsinfo.nih.gov/guidelines

http://aidsinfo.nih.gov/guidelines

What’s New in the Pediatric Guidelines?

• When to Start Antiretroviral Therapy (ART)– Recommendations for naïve infants

< 12 months and those older than 1 year

• What to Start; pediatric trial updates

• Monitoring updates for blips and lab evaluations

• Toxicity management table updated

What’s New in the Pediatric Guidelines?

• Treatment Failure with focus on adherence assessment/management

• Resistance Testing section expanded

• Pediatric Antiretroviral Drug Information section reorganized and updated

At what ages should an exposed infant be tested for HIV?

A. Birth, 1m, 2m, 3m

B. 2m, 4m, 6m, 18m

C. 14 days, 1m, 4m

D. Birth, 1m 4m, 6m

E. Birth, 14 days, 3m, 6m

A. B. C. D. E.

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ART Initiation: Infants <12 Months

• Youngest children are at high risk of rapid disease progression.

• Clinical and laboratory markers are poor indicators of risk of rapid progression in infants.

• RCT and observational data suggest early ART reduces risk of HIV progression and death.

• Limited information on appropriate ARV dosing.

August 2011 AETC National Resource Center, www.aidsetc.org

Indications for Initiation of ART in Children <12 Months of Age

Criteria Recommendation

Treat all, regardless of clinical symptoms, immune status, or viral load

Assess and discuss issues associated with adherence before therapy is initiated (AIII)

Treat (AII)


ART: Age ≥12 Months

• Children with AIDS or significant symptoms are at high risk of disease progression and death; in them, treatment should be initiated regardless of immunologic or virologic status (AI)


ART: Age ≥12 Months (2)

• Asymptomatic or mildly symptomatic children are at lower risk of disease progression; CD4 count and VL may be useful in determining need for ART.

• Younger age at initiation of therapy has been associated with improved immune response and rapid growth reconstitution.

• Higher CD4 count or % is associated with better immune response to ART.



• For asymptomatic children, ART now recommended at higher CD4 count or %, though few data available to define optimal CD4 threshold for starting ART.

• At lower CD4 levels, recommendation to treat is stronger (and supporting data are more substantial)



• Factors to consider in deciding when to initiate therapy in asymptomatic children >12 mos

– Increasing HIV RNA levels (e.g., approaching 100,000 copies/mL)

– CD4 count or percentage values approaching age-related threshold for treatment

– Development of clinical symptoms

– Ability of caregiver and child to adhere to regimen


At what age can you use the CD4 cut off used for adults to start HAART in

asymptomatic children?

A. 6

B. 5

C. 12

D. 4

E. 13

A. B. C. D. E.

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What is the CD4 cut off used in adults?

A. 350

B. 200

C. 500

D. 450

E. 600

A. B. C. D. E.

0% 0% 0%0%0%

Indications for Initiation of ART in Children ≥1 - <5 Years of Age


AIDS or significant HIV-related symptoms (Clinical

Category C or most Clinical Category B

conditions) regardless of CD4 percentage/count

or plasma HIV RNA level

Treat (AI*)

CD4 <25% regardless of symptoms or HIV RNA Treat (AII*)

Asymptomatic or mild symptoms plasma RNA ≥100,000 copies/mL regardless of CD4 percentage/count

Treat (BII)

Asymptomatic or have mild symptoms with a plasma RNA <100,000 copies/mL and CD4 percentage >25%

Consider treatment

(CIII)


Indications for Initiation of ART in Children >5 Years of Age


AIDS or significant HIV-related symptoms (Clinical Category C or most Clinical Category B conditions) regardless of CD4 percentage/count or plasma HIV RNA level

Treat (AI)

CD4 ≤500, regardless of symptoms or HIV RNA Treat

(AI forCD4 count <350 and BII*

for CD4 count 350–500)

Asymptomatic or have mild symptoms with a plasma RNA ≥100,000 copies/mL regardless of CD4 percentage/count

Treat (BII)

Asymptomatic or have mild symptoms with a plasma RNA <100,000 copies/mL and CD4 percentage >25%

Consider treatment

(CIII)


Initial Combination Therapyfor ARV-Naïve Children

• Initial therapy should include at least 3 ARVs, from at least 2 drug classes, to include:– Either an NNRTI or a PI (boosted or

unboosted), plus

– A dual-NRTI backbone (AI)


Which ARV was most recently FDA approved for children?

A. Rilpivirine

B. Efavirenz

C. Raltegravir

D. Etravirine

E. Tenofovir

A. B. C. D. E.

0% 0% 0%0%0%

Current ARV MedicationsNRTI Abacavir (ABC) Didanosine (ddI) Emtricitabine (FTC) Lamivudine (3TC) Stavudine (d4T) Tenofovir (TDF) Zidovudine (AZT,

ZDV)

NNRTI Efavirenz (EFV) Etravirine (ETR) Nevirapine (NVP) Rilpivirine (RPV)

PI Atazanavir (ATV) Darunavir (DRV) Fosamprenavir (FPV) Indinavir (IDV) Lopinavir (LPV) Nelfinavir (NFV) Ritonavir (RTV, /r) Saquinavir (SQV) Tipranavir (TPV)

Fusion Inhibitor Enfuvirtide (ENF, T-20)

CCR5 Antagonist Maraviroc (MVC)

Integrase Inhibitor Raltegravir (RAL)

= FDA approved for pediatric treatment


NNRTI-Based Regimens

Advantages

• Lower risk of dyslipidemia and fat maldistribution than seen with PIs

• PI sparing• More palatable • Lower pill burden

Disadvantages

• Risk of virologic failure if exposed to single-dose NVP as part of PMTCT

• Single mutation can confer high-level resistance; cross-resistance between EFV and NVP

• Risk of serious or life-threatening rash and hepatitis (rare)

• Potential for multiple drug interactions


PI-Based Regimens

Advantages• NNRTI-sparing

• Efficacy well documented

• Resistance requires multiple mutations

• Targets HIV at 2 steps of viral replication

Disadvantages

• Metabolic complications

• Potential for multiple drug interactions

• Higher pill burden

• Poor palatability of liquid formulations


Initial Treatment: Preferred Regimens

1 LPV/r should not be given to neonates before a postmenstrual age (first day of the mother’s last menstrual period to birth plus time elapsed after birth) of 42 weeks and a postnatal age of at least 14 days.

² EFV is currently available only in capsule and tablet form and should be used only in children age >3 years who weigh >10 kg. Not recommended for adolescent females who are sexually active and may become pregnant unless adequate contraception can be ensured.

Children age >14 days and <3 years1

2 NRTIs + LPV/r1 AI

Children age >3 years 2 NRTIs + EFV2

2 NRTIs + LPV/r

Children age >6 years 2 NRTIs + ATV (with low-dose RTV)

2 NRTIs + EFV2

2 NRTIs + LPV/r AI


Initial Treatment: Alternative Regimens

Children of any age

2 NRTIs + NVP3

Children age >6 years

2 NRTIs + DRV (with low-dose RTV) AI2 NRTIs + FPV (with low-dose RTV)

3 NVP should not be used in postpubertal girls with CD4 count >250, unless the benefit clearly outweighs the risk


Initial Treatment: Regimens for Use in Special Circumstances

2 NRTIs + ATV unboosted (for treatment-naïve adolescents age >13 years and body weight >39 kg) 2 NRTIs + FPV unboosted (for children age >2 years) 2 NRTIs + NFV (for children age >2 years) ZDV + 3TC + ABC*

* Test for HLA-B*5701 before initiation of ABC; do not give ABC to children who are HLA-B*5701 positive. (AII*).


Initial Treatment: 2-NRTI Backbone Options

Preferred ABC* + (3TC or FTC) (age >3 mos) TDF + (3TC or FTC) (adolescents age >12 years and Tanner 4 or 5 only) ZDV + (3TC or FTC)

Alternative ddI + (3TC or FTC) BI TDF + (3TC or FTC) (adolescents age >12 years and Tanner 3) BI ZDV + ABC* ZDV + ddI

Use in special circumstances

d4T + (3TC or FTC) TDF + (3TC or FTC) (adolescents age >12 years and Tanner 2)

* Test for HLA-B*5701 before initiation of ABC; do not give ABC to children who are HLA-B*5701 positive. (AII*).


Initial ARV Therapy: Components Not Recommended

Insufficient Data for use in Initial Therapy

Triple-class regimens, including NRTI + NNRTI + PI

Maraviroc Etravirine Raltegravir Tenofovir (Insufficient data in children<12

years or children >12 and Tanner 1)

Enfuvirtide EFV for children age <3 Rilpivirine and rilpivirine-containing

regimens


Initial ARV Therapy: Components Not Recommended (2)

Potential toxicity, inferior potency,or inconvenient dosing

ATV (unboosted) in children<13 years and/or <39 kg

IDV PTV NFV in children <2 years SQV RTV (full dose) EFV in first trimester of pregnancy or in

girls of childbearing potential NVP initiation in girls with CD4 >250 or

boys >400 Dual PI regimens (full dose) NLF in age <2 years


ARV Components Never Recommended as Part of an ARV Regimen for Children

Components Rationale Exception

EFV in 1st trimester of pregnancy or if adequate contraception cannot be assured

Potential for teratogenicity

When no other ARV option is available and potential benefits outweigh risks

NVP in adolescent girls with CD4 >250 or adolescent boys with CD4 >400

Increased incidence of symptomatic hepatic events

Only if benefit clearly outweighs the risk

Unboosted SQV, DRV or TPV

Poor bioavailability

Inferior virologic activity

Only if benefit clearly outweighs the risk


ARV Components Never Recommended as Part of an ARV Regimen for Children

Components Rationale Exception

ATV plus IDV Potential additive risk of hyperbilirubunemia

No exceptions

Dual-NNRTI combinations

Enhanced toxicity No exceptions

Dual NRTI combinations: d4T plus ZDV

Antagonistic effect on HIV

No exceptions

Dual NRTI combinations: 3TC plus FTC

Similar resistance profile and no additive benefit

No exceptions


ARV Regimens Never Recommended for Children

Regimen Rationale Exceptions

Single-drug therapy Rapid development of resistanceInferior antiviral activity

Prophylaxis for HIV-exposed infants3TC or FTC “bridging regimen”

Two NRTIs alone Rapid development of resistanceInferior antiviral activity

Not recommended for initial therapyIn a child on 2 NRTIs with good virological response

TDF plus ABC plus (3TC or FTC)

High rate of early viral failure No exceptions

TDF plus ddI plus (3TC or FTC)

High rate of early viral failure No exceptions


How often should you monitor labs in HIV infected children?

A. Every 2 months

B. Every 4-6 months

C. Every 1-2 months

D. Every 3-4 months

E. Every 6-12 months

A. B. C. D. E.

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Monitoring of Children on ART

• Baseline (before ART)– Clinical history, CBC and diff, chemistries

(incl. electrolytes, creatinine, calcium, phosphorus, hepatic transaminases), glucose, lipid panel and u/a.

– Urinalysis- NEW at baseline and reevaluate every 6-12 months

– Genotype


Monitoring of Children on ART(2)

• Within 1-2 weeks of starting new ARV regimen– Screen for side effects, assess adherence (AIII)

• Within 4-8 weeks (AIII)

– Screen for side effects, evaluate virologic response (AIII)

– CD4/%, HIV RNA, CBC, chemistries (incl. renal panel and liver function tests)

• For stable patients, follow up at least every 3-4 months (AII*)

– Monitor adherence, toxicity, efficacy (AII*)

• More frequent evaluation may be needed following initiation or change in therapy (AIII)* For children receiving nevirapine, serum transaminase levels should be measured every 2

weeks for the first 4 weeks of therapy, then monthly for 3 months, followed by every 3 to 4 months.


Monitoring Viral Loads

– Panel noted that temporary viral load elevations between the level of detection and 1,000 copies/ml are often detected in children and are blips.

– “Blips”: Isolated episode of viremia <1000 copies/mL followed by return to viral suppression. Common and not generally reflective of virologic failure.

Toxicities and their management

• New sections added to table 17 on CNS toxicity, gastrointestinal effects, nephrotoxicity and peripheral nervous system toxicity

• CNS: LPV/r EFV, RAL, TPV

• GI: Nausea/vomiting, diarrhea, pancreatitis

• Renal: IDV, ATV, TDF

• Peripheral Nervous System : d4T, ddI

Overview of Treatment Failure (2)

– Evaluate the cause of treatment failure, especially adherence (the #1 cause of treatment failure)

– Not all ART failures require immediate change in therapy (AII)

– Manage treatment failure in collaboration with pediatric HIV specialist (AI*)

• Bridging regimens


Virologic Failure

– Incomplete virologic response to therapy or viral rebound after achieving virologic suppression

• Incomplete response to therapy: – <1.0 log10 decline in HIV RNA from baseline after 8-12

weeks of ART; or– HIV RNA >200 copies/mL after 6 months of ART; or– Repeated HIV RNA above the level of detection after

12 months of therapy using most sensitive assay


13 yr. old in clinic has viral load of 1975 copies/ml after 5 years of undetectable viral loads.

What would you do next?

A. Discuss adherence and follow up in 1 month.

B. Discuss adherence, adjust doses, test for resistance and follow up in 2-4 weeks.

C. Discuss adherence, adjust doses and follow up in 3 months.

D. Change medications and discuss adherence. A. B. C. D.

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Resistance Testing• Recommended :

– Before initiation of ART for all treatment-naive children (AII) (genotype preferred) (AIII)

– Before changing ART in patients with treatment failure (AI*)

• In setting of viral failure, ensure patient is on current regimen or within 4 weeks of discontinuation (AII*)


Resistance Testing

– Use phenotype (usually in addition to genotype) for known or suspected complex drug resistance (BIII)

• Absence of detectable resistance to a drug does not insure its success

– Current assays are not sensitive enough to exclude the presence of resistant virus

– ARVs history and previous resistance tests should be reviewed when choosing new ART after virologic failure (AII)


Tropism (Viral Coreceptor) Assays

• Detects presence of CCR5 and CXCR4 coreceptors

• Standard test is phenotypic assay, requires HIV RNA >1,000 copies/mL

– Genotypic assay available; few clinical data

• Should be performed before starting patient on CCR5 antagonist (CCR5 antagonists not effective in patients with CXCR4 virus) (AI*)

• Consider for patients who have virologic failure on a CCR5 inhibitor (AI*)


Pediatric Antiretroviral Drug Information

• Abacavir: Once daily dosing 16mg/kg/day max 600mg; in clinically stable undetectable children

• Lamivudine: Once daily (300mg daily) for youth ≥16 yrs who weigh ≥ 50kg

• Stavudine: Use only 30mg dose in adolescents

• Tenofovir: Bone Mineral Density effects and renal function effects updated in children


• Efavirenz: Interpatient variabiltiy due to CYP450 genes, TDM discussed.

• Nevirapine: Extended release not approved for <18 yr.

• Rilpivirine: No pediatric data.


• Darunavir: Once daily only for naïve 12-18 yrs if >40kg Dose at (800/100 mg).

• Lopinavir/ritonavir: Cardiovascular toxicity in preterm infants- use only after postmenstrual age of 42 weeks and a postnatal age of at least 14 days.

• Saquinavir: Pretherapy ECG recommended due to prolonged PR and QT; do not use if has prolonged QT or on meds that effect QT.

References• Most slides in this presentation were

prepared by Mary Jo Hoyt, MSN; Carolyn K Burr, EdD, RN; and Susa Coffey, MD for the AETC National Resource Center in August 2011.

• Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, August 11, 2011; Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PediatricGuidelines.pdf (Accessed10-14-2012).

http://aidsinfo.nih.gov/contentfiles/lvguidelines/PediatricGuidelines.pdf

http://aidsinfo.nih.gov/contentfiles/lvguidelines/PediatricGuidelines.pdf

Perinatal HIV Treatment Guidelines Update

Ana M. Puga, MD

Comprehensive Family AIDS Program

Children’s Diagnostic & Treatment Center

Fort Lauderdale, FL

DHHS Guidelines • September 2011 guidelines updated July

31, 2012, including supplement update on Safety & Toxicity of Individual Antiretroviral Agents in Pregnancy

• For full set of guidelines, visit the AIDSinfo website at http://aidsinfo.nih.gov/guidelines

http://aidsinfo.nih.gov/guidelines

When do you test a pregnant woman for HIV?

A. When she starts prenatal care.

B. When she has an STI.

C. When she gets sick.

D. At entry into Prenatal Care and at 28-32 weeks or at delivery if not done in third trimester

E. Every trimester.

A. B. C. D. E.

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What’s New in the Perinatal Guidelines?

• New Clinical Trial results• More info on Preconception Counseling,

including drug interactions and contraceptives • Antepartum care expanded, including

management of naïve pregnant women and those already on ARVs

• New ARVs recommended in preferred category and category changes for other ARVs

What’s New in the Perinatal Guidelines?

• Intrapartum care changes- no IV ZDV needed if woman is undetectable (BII)

• Postpartum care updates for infant prophylaxis and monitoring

• Discussion of premastication

Strength of Recommendations

A: Strong recommendation for the statementB: Moderate recommendation for the statementC: Optional recommendation for the statement

I: One or more randomized trials with clinical outcomes and/or validatedlaboratory endpointsII: One or more well-designed, nonrandomized trials or observationalcohort studies with long-term clinical outcomesIII: Expert opinion

Lesson Learned from Clinical Trials• Breastfeeding and Nutrition (BAN) study

– Postpartum maternal triple drug prophylaxis vs. infant NVP in women with CD4-cell counts ≥ 250 cells/mm3

– Arm 1 (control):• Maternal ZDV/3TC for 1 week; infant single dose NVP +

ZDV/3TC for 1 week

– Arm 2: Control as above, then• Maternal ZDV/3TC/LPV/r for 6 months

– Arm 3: Control as above, then • Infant NVP for 6 months

– Results• No significant difference between maternal triple-drug

prophylaxis (Arm 2) and infant NVP (Arm 3) at 28 and 48 weeks


You have a 26 year old female who wants to start ARVs with a “one pill a day” regimen. What do you discuss with her?

A. Proper dosing, side effects, adherence, resistance and cost

B. Proper dosing, side effects, adherence, and resistance

C. Proper dosing, side effects, adherence, resistance, and preconception counseling, including contraception

D. Proper dosing, side effects, adherence and birth control

A. B. C. D.

0% 0%0%0%

Preconception Counseling

• Contraception– Updated information on hormonal contraceptive

interactions with ARVs

• Reproductive options for serodiscordant couples– Use of ART is recommended for the HIV-infected

partner, with maximal viral suppression achieved prior to attempting conception

• For CD4-cell counts ≤550 cells/mm3 (AI)

• For CD4-cell counts >550 cells/mm3 (BIII)


Preconception Counseling (2)

• Pre-exposure prophylaxis (PrEP)– Recommendations

• Periconception administration of ARV PrEP may offer an additional tool to reduce the risk of sexual transmission (CIII).

• The utility of PrEP of the uninfected partner when the infected partner is receiving ART has not been studied.

– Discussion on PrEP includes information on• Studies• Counseling• Laboratory testing• Monitoring individuals on PrEP


Antepartum Care

• Initial assessment of HIV-infected pregnant women should include– Screening for Hepatitis C and tuberculosis

infection– A history of side effects or toxicities from

prior ARV regimens

• Use of effective ART to reduce transmission to uninfected partners– Discussion of HPTN 052 trial


Antiretroviral Drugs During Pregnancy

• Modified drug categories: Preferred, Alternative, Use in special circumstances

• Drugs that have changed categorization– Didanosine and stavudine

• Use in special circumstances due to toxicity concerns

– Atazanavir• Preferred due to increased information on safety

– Darunavir• Alternative PI for use in ARV-naïve pregnant women

– Raltegravir• Use in special circumstances when preferred or

alternative agents cannot be used


ARV-Naïve HIV-Infected Pregnant Women

• The decision to initiate an ARV drug regimen in the 1st trimester or after 12 weeks gestation depends on (AIII)– CD4-cell count– HIV RNA levels– Maternal conditions

• Earlier initiation of ARV combination therapy may be more effective in reducing transmission but risks and benefits must be weighed


HIV-Infected Pregnant Women Receiving ARV Therapy

• Women receiving efavirenz as part of an effective ART regimen may continue it during pregnancy (CIII)– The risk of neural tube defects is limited to

the first 5 or 6 weeks of pregnancy• Most pregnancies are not recognized before 4 to

6 weeks

– ARV changes can lead to loss of viral control and increased risk of perinatal transmission


Failure of Viral Suppression• Discussion of the use of raltegravir in

late pregnancy for women with high viral loads– Efficacy and safety of this approach has not

been evaluated– Concerns that the addition of a single agent

to a failing regimen may • Increase resistance • Decrease future effectiveness


ARVs and Pregnancy Outcome• Guidelines include a table of studies assessing

the association between ART and preterm delivery (Table 7)

• 17 studies reviewed from sites throughout the globe

• 10 associated with Preterm Delivery• 7 Not associated with Preterm Delivery• Association not yet confirmed given variability of

study data and results • All but one US study (patients with advanced

disease) did not show an association

What is the recommended delivery option for a 30 y/o HIV+ G3P2 on ARVs with a viral load of 1800c/ml?

A. Vaginal delivery at term

B. C-section at term

C. Vaginal delivery at 38 weeks

D. C-section at 38 weeks

E. C-section at 38 weeks with 3 hours of ZDV prior to procedure

A. B. C. D. E.

0% 0% 0%0%0%

When can IV ZDV be omitted in the delivery process?

A. When the viral load near delivery is <1000 copies/ml

B. When the viral load near delivery is < 48 (<20) copies/ml

C. When the viral load near delivery is < 48 (<20) copies/ml and a C-section is planned

D. When a woman on combination ARVs has undetectable viral load near delivery

A. B. C. D.

0% 0%0%0%

Intrapartum Care

• IV zidovudine is no longer required for HIV-infected women receiving combination ARV regimens who have HIV RNA <400 copies/ml near delivery (BII)

• HIV-infected women with HIV RNA ≥400 copies/ml (or unknown) near delivery should be administered IV zidovudine during labor regardless of mode of delivery (AI)– IV is the recommended route of zidovudine

administration• Oral administration may be considered if IV is not

possible


Postpartum Care

• Neonatal dosing recommendations for – Zidovudine– Nevirapine

• Neonatal prophylaxis regimens – Discussion on the NICHD-HPTN 040 study– Concerns about lopinavir/ritonavir in neonates

• Pharmacokinetic data on nevirapine in preterm infants


All these are ways HIV can be transmitted?

A. Blood contact, exchange of sexual fluids, during pregnancy and labor/delivery

B. Blood contact, exchange of sexual fluids, during pregnancy and labor/delivery, and breastfeeding

C. Blood contact, exchange of sexual fluids, during pregnancy and labor/delivery, breastfeeding and premastication

A. B. C.

0% 0%0%

Postpartum Care (2)

• Management of the HIV-exposed infant– Infants receiving zidovudine/lamivudine-

containing prophylaxis (AI)• Higher risk for hematological toxicity (vs.

zidovudine alone)• Recheck hemoglobin and neutrophil counts at 4

weeks after initiation of prophylaxis

– Health care providers should routinely inquire about premastication of food fed to infants, instruct HIV-infected caregivers to avoid this practice, and advise on safer feeding options (AII)


References• Most slides from the National AETC Resource

Center, What’s New in Perinatal Guidelines?, August 2012, www.aidsetc.org (Accessed 10/14/2012).

• Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf (Accessed 10/14/2012).

http://www.aidsetc.org/

http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf

http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf

pediatric hiv treatment guidelines update

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pediatric guidelines

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