Switch Strategies, Special Situations

• The general indications for switching when virologically suppressed are as for adults, 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 high-barrier once daily low pill burden regimens with low toxicity profiles and optimal efficacy data. For example, in children aged less than 3 years commenced on liquid LPV/r, switching to once daily INSTI (DTG from 4 weeks or BIC from 2 years of age and 14 kg) is recommended
• If “preferred” options become available for a child as they get older, then a switch to this preferred option is recommended
• Children and their carers should be involved in discussing the relative risk/benefit of switching when well and stable on an effective regimen
• Switching to dual therapy is not routinely recommended, but is an option for simplification, and can be considered on a case by case basis in adherent children and adolescents
• Simplification to monotherapy and treatment interruptions are not recommended

• Seek specialist expert advice e.g. through an MDT or PVC. If local MDT or PVC are unavailable, an international PVC is accessible by contacting the Guideline Team.
• Adolescents of child bearing potential: first line options for adolescents of child bearing potential share the same considerations as discussed elsewhere in the EACS Guideline, see Pregnancy, and should bear in mind contraceptive choices and DDIs with ARVs, see DDIs between contraceptives and ARVs
• DDI: see Drug-drug Interactions and Other Prescribing Issues for information on avoidance and management of DDI. In addition to the information on interactions in this guideline a further useful resource is provided by University of Liverpool here
• HBV co-infection: requires an ART regimen that includes TAF or TDF in the NRTI backbone typically with 3TC or FTC. If TDF/TAF not available, alternatives should be discussed within an MDT or PVC. For recommendation in adults with HBV/HIV co-infection, see Treatment and Monitoring of Persons with HBV/HIV Co-infection
• HCV co-infection: DAAs against HCV are licensed and available in paediatric formulations. Seek specialist advice for choice of curative HCV therapy for children and adolescents with HCV co-infection. For recommendation in adults with HCV/HIV co-infection, see Treatment and Monitoring of Persons with HCV/HIV Co-infection
• TB co-infection*: from 4 weeks of age DTG bid is the preferred anchor drug in the context of rifampicin administration. Doubling the dose of RAL bid can be considered as an alternative. Over 3 years of age EFV is also an alternative option if DTG is not available. Super boosted LPV/r with additional ritonavir to reach a 1:1 ratio may also be considered when paediatric INSTI formulations are not available. Specialist advice should be sought with therapeutic drug monitoring (TDM) recommended where available. For treatment recommendation in adults with TB/HIV co-infection, see ART in TB/HIV Co-infection

* these recommendations also apply when using rifampicin for other indications