Bamford, A

Foster, C

Klein, N

PENTA Guidelines Writing Group and PENTA steering committee, .

Turkova, A

Welch, S

UCL Discovery

Paediatric European Network for Treatment of AIDSTreatment Guideline 2016 update: antiretroviral therapyrecommended for all children living with HIVC Foster,1 A Bamford,2 A Turkova,3 S Welch4 and N Klein2,5 On behalf of the PENTA Guidelines Writing Group andPENTA steering committee1The Family Clinic, Imperial College NHS Trust, London, UK, 2Paediatric Infectious Diseases, Great Ormond StreetHospital, London, UK, 3MRC Clinical Trials Unit, London, UK, 4Paediatrics, Birmingham Heartlands Hospital,Birmingham, UK and 5Institute of Child Health, London, UKThe PENTA Steering committee now recommendsantiretroviral therapy (ART) for all children and adoles-cents living with HIV. Priority should be given to infantsand children under 3 years of age, to adolescents, and tochildren with symptoms and/or low age-specific CD4counts.The 2015 PENTA guideline recommended consideringART for all children diagnosed before their third birth-day, with CD4 count guided thresholds for older chil-dren [1]. Following the results of the START - StrategicTiming of AntiRetroviral Treatment study, World HealthOrganization (WHO), US and European guidelines nowrecommend treatment for all HIV-infected adults andadolescents irrespective of CD4 count. Such recommen-dations take into account the benefits of universal treat-ment in reducing onward transmission, includingmother-to-child transmission. WHO paediatric guidelinesrecommend treatment for all children, with prioritizationof children under 5 years old and those with symptomsor low CD4 counts.The Children with HIV Early Antiretroviral Therapy(CHER) study provided strong randomized controlled trial(RCT) evidence for early treatment of all infants. RCT evi-dence for the benefit of ART for children aged 1–10 years with good CD4 counts is lacking. PreviousPENTA guidelines extended the recommendation for allchildren under 3 years because of the potential for rapiddisease progression at higher CD4 counts [1]. Universaltreatment for all adolescents (WHO definition 10–19 years) can now be recommended based on extrapola-tion of adult START data and in prevention of onwardtransmission to partners as this population becomes sex-ually active. There is no equivalent to START data onshort- to medium-term benefits of early ART in youngerchildren, where there is no additional benefit of preven-tion of onward transmission.We recognize that, in the absence of RCT data, thereare potential concerns about the earlier start of lifelongART in children, with insufficient data on cumulativetoxicity and concerns regarding adherence because ofpoor palatability and limited combination paediatric for-mulations. However, there is increasing evidence of thelonger term benefits of early ART, including reducedmortality in low- and middle-income countries, improvedneurodevelopmental, growth and pubertal outcomes,improved immune reconstitution and reduced inflamma-tion and latent reservoir cohort data also demonstrate areduced risk of virological failure when ART is started inchildhood compared with adolescence [2–5].On this basis, we now also conclude that all childrenshould be started on ART. For children with good CD4counts, time can be taken to address adherence and psy-chosocial issues, but discussion on starting treatmentshould be initiated soon after the diagnosis, and childrennot on ART closely monitored.While concern about the additional cost of providingART to all children in low- and middle-income settingsmay require individual countries to analyse the financialimpact when changing national guidelines, in Europeancohorts more than 90% of diagnosed children are alreadyon ART.The potential benefits of ART outweigh the potentialproblems for children of all ages living with HIV. Thetime is now right to recommend ART for all children withHIV infection.Correspondence: Caroline Foster, The Family Clinic, Imperial College NHSTrust, London, UK. Tel: 0207 8866349; fax: 020 7886 2045;e-mail: caroline.foster@imperial.nhs.ukThe copyright line for this article was changed on 01 September 2016after original online publication.This is an open access article under the terms of the Creative CommonsAttribution-NonCommercial-NoDerivs License, which permits use and dis-tribution in any medium, provided the original work is properly cited, theuse is non-commercial and no modifications or adaptations are made.1DOI: 10.1111/hiv.12399© 2016 The Authors HIV Medicine published byJohn Wiley & Sons Ltd on behalf of British HIV Association HIV Medicine (2016)LETTER TO THE EDITORAppendix 1: PENTA guidelines writinggroupJintanat Anworanich, Alasdair Bamford, Diane Bastiaans,Stefania Bernardi, Rosa Bologna, David Burger, Alexan-dra Compagnucci, Elena Chiappini, Polly Clayden, Mari-nella Della Negra, Katja Doerholt, Catherine Dolfus,Albert Faye, Caroline Foster, Vania Giacomet, MarcHainaut, Nigel Klein, Mark Lallemant, Hermione Lyall,Laura Marques, Diane Melvin, Eleni Nastouli, Tim Nie-hues, Ton Noguera, Jolanta Popielska, Filipa Prata, PabloRojo, Henriette Scherpbier, Delane Shingadia, GarethTudor-Williams, Anna Turkova, Steve Welch.References1 Bamford A, Turkova A, Lyall EGH, Foster C, Klein N, Welch S.on behalf of PENTA. Paediatric European Network forTreatment of AIDS (PENTA) guidelines for treatment ofpaediatric HIV-1 infection 2015: optimizing health inpreparation for adult life. HIV Med. 2015 Feb 3. doi: 10.1111/hiv.12217. [Epub ahead of print].2 Lewis J, Walker AS, Castro H et al. Age and CD4 count atinitiation of antiretroviral therapy in HIV-infected children:effects on long-term T-cell reconstitution. J Infect Dis 2012;205 : 548–556.3 Schomaker M, Davies MA, Malateste K et al. Growth andmortality outcomes for different antiretroviral therapyinitiation criteria in children aged 1-5 years: a causalmodelling analysis. Epidemiology 2016 Mar; 27:237–246.4 Montagnani C, Chiappini E, Bonsignori F et al. Long-termeffect of highly active antiretroviral therapy on immunologicfeatures in children. Pediatr Infect Dis J 2015; 34 (5 Suppl 1):S3–S6.5 Goodall RL, Collins IJ, Child T et al. Durability of first-lineantiretroviral therapy (ART) in children in the EuropeanPregnancy and Paediatric HIV cohort collaboration (EPPICC). 8thIAS Conference on HIV Pathogenesis, Treatment and Prevention.Vancouver, Canada, 19–22 July 2015 [Abstract TUPEB 304].© 2016 The Authors HIV Medicine published byJohn Wiley & Sons Ltd on behalf of British HIV Association HIV Medicine (2016)2 Letter to the Editor

Paediatric European Network for Treatment of AIDS Treatment Guideline 2016 update: antiretroviral therapy recommended for all children living with HIV

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Paediatric European Network for Treatment of AIDS Treatment Guideline 2016 update: antiretroviral therapy recommended for all children living with HIV

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