In 16 European countries and Thailand, researchers investigated time to switch to second-line therapy among children with human immunodeficiency virus. By 5 years of antiretroviral therapy (ART), 1 in 5 children switched to a second-line regimen, with two-thirds failure related. They observed an increased risk of switch with advanced HIV, older age, and nevirapine (NVP)-based regimens.

Methods

• Researchers included children aged <18 years initiating combination ART (≥2 nucleoside reverse transcriptase inhibitors [NRTIs] plus nonnucleoside reverse transcriptase inhibitor [NNRTI] or boosted protease inhibitor [PI]).
• They defined switch to second-line as:
• (i) Change across drug class (PI to NNRTI or vice versa) or within PI class plus change of ≥1 NRTI;
• (ii) Change from single to dual PI; or
• (iii) Addition of a new drug class.
• They estimated cumulative incidence of switch with death and loss to follow-up as competing risks.

Results

• Researchers included 3,668 children.
• At ART initiation, median age was 6.1 (interquartile range (IQR), 1.7–10.5) years.
• They observed that initial regimens were 32% PI based, 34% NVP based, and 33% efavirenz based.
• Follow-up was performed for a median period of 5.4 (IQR, 2.9–8.3) years.
• At 5 years, cumulative incidence of switch was 21% (95% confidence interval, 20%–23%).
• Significant regional variations were noticed in cumulative incidence.
• Median time to switch was 30 (IQR, 16–58) months.
• In relation to treatment failure, two-thirds of switches were observed.
• Multivariable analysis suggested an increased risk of switch in association with older age, severe immunosuppression and higher viral load (VL) at ART start, and NVP-based initial regimens.