COVID-19 Management: Updated Guidance for Children With HIV Infection

Guidelines for the Prevention and Treatment of Opportunistic Infections in Children With and Exposed to HIV were updated on July 3, 2024, to include recommendations regarding the prevention and treatment of COVID-19 infection.

These guidelines were developed collaboratively by the Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Department of Health and Human Services Panel on Opportunistic Infections in Children With and Exposed to HIV infection.

The guidelines are intended for health care providers and other health care workers who deliver care to children who are infected with or have been exposed to HIV. The new recommendations were formulated by specialists in pediatric HIV and general infectious diseases. Opportunistic infections among this patient population include giardiasis, human papillomavirus, malaria, and syphilis, and the prevention and treatment of these conditions are covered in great detail within these guidelines.

In 2021, a panel of experts recommended that these guidelines be revised and shift in focus to ensure alignment with the evolving pediatric HIV landscape. In response, a new section on the management of COVID-19 infection in HIV-exposed or infected children was added to the guidance.

The panel’s recommendations for this population regarding vaccination and pre-exposure prophylaxis in the prevention of COVID-19 infection, including severe disease, are as follows:

COVID-19 Vaccination

• All children aged 6 months and older with HIV infection, as well as members of their household members and close contacts, should receive the COVID-19 vaccination regardless of CD4 T-cell count or HIV viral load (strong recommendation)
• Vaccination against COVID-19 should not be delayed while awaiting immune reconstitution, despite the fact that vaccine response may improve after the initiation of antiretroviral therapy (strong recommendation)

Pemivibart

• Monoclonal antibody treatment with pemivibart should be considered for COVID-19 prevention in children aged 12 years and older with HIV and severe immunosuppression who weigh at least 40 kg (moderate recommendation)
• Pemivibart may also be considered for COVID-19 prevention among children with moderate to no immunosuppression in whom COVID-19 vaccines are either contraindicated or unavailable (optional recommendation)

The panel notes that monoclonal antibody treatment, including pemivibart, should not serve as a substitute for COVID-19 vaccination in vaccine-eligible pediatric populations.

Ritonvair-Boosted Nirmatrelvir, Cobicistat, and Remdesivir 

• For the treatment of laboratory-confirmed or clinically suspected mild to moderate COVID-19 infection among HIV-positive children in outpatient settings, ritonavir-boosted nirmatrelvir should be considered for those aged 12 years and older who weight at least 40 kg who are at high risk for severe disease due to advanced or untreated HIV (moderate recommendation)
• Treatment with ritonavir-boosted nirmatrelvir should be initiated within 5 days of symptom onset (moderate recommendation) and can be administered concomitantly with antiretrovirals, including those containing ritonavir or cobicistat (strong recommendation)
• Treatment with remdesivir may also be considered for the treatment of confirmed or clinically suspected mild to moderate COVID-19 in HIV-positive children, particularly among those aged 28 days and older who weigh at least 3 kg and are at high risk for severe disease progression (optional recommendation)
• Remdesivir should be initiated within 7 days of COVID-19 onset; however, initiation after 7 days of symptoms may be appropriate for children with severe immunosuppression (optional recommendation)

According to the panel, ritonavir-boosted nirmatrelvir is the preferred treatment option for nonhospitalized children with HIV infection aged 12 years and older at high risk for severe COVID-19. However, the panel notes that remdesivir may be considered if ritonavir-boosted nirmatrelvir is unavailable or contraindicated (moderate recommendation).

COVID-19 Management for HIV-Exposed or Infected Pediatric Inpatients

• Remdesivir should be considered for COVID-19 treatment in HIV-positive pediatric inpatients aged 28 days who weigh at least 3 kg and require supplemental oxygen (moderate recommendation), including those with severe or critical illness (strong recommendation)
• Corticosteroids, such as dexamethasone, may also be considered for COVID-19 treatment in HIV-positive pediatric inpatients who require supplemental oxygen (moderate recommendation), particularly for those with severe or critical illness whose need for oxygen rapidly increases during hospitalization (strong recommendation)

According to the panel, “[P]revention and treatment of OIs [opportunistic infections] in children with HIV remain important, even in the combination ART [antiretroviral therapy] era.”

This article originally appeared on Infectious Disease Advisor