Key recommendations
- Immediately assess all children presenting following a potential HIV exposure for PEP, ideally in conjunction with a paediatric infectious diseases specialist
- includes following alleged sexual abuse, human bites and splash injuries.
- Consider whether a forensic examination is indicated, and if so, refer to your local child protection unit in a timely manner for a multidisciplinary assessment. Ensure a mandatory notification has been made if required.
- Recommend that all children younger than 16 years who qualify for HIV PEP receive combination therapy with three drugs at appropriate dosages:
- the full 28-day PEP course should be provided at the time of initial presentation
- in children younger than 6 years OR weighing less than 25 kg, the preferred PEP regimen is lamuvudine + zidovudine + dolutegravir OR raltegravir
- in children older than 6 years, the preferred regimen is:
- IF weighing more than 35 kg, emtrictabine + tenofovir disoproxil + dolutegravir OR raltegravirIF weighing more than 25 kg , Biktarvy®.
- Consider the risk of hepatitis B (refer to Australian Immunisation Handbook).
- Baseline PEP testing: EUC and LFTs for all children; FBC for children prescribed zidovudine.
- Consider empiric azithromycin and ceftriaxone if STI testing or follow-up is not guaranteed.
Few randomised controlled trials of HIV PEP in children have been conducted.113 Recommendations are largely informed by data outlined in section: Background: evidence supporting the efficacy of PEP in preventing HIV acquisition, and expert opinion which includes the collective experience of the Australian and New Zealand Paediatric Infectious Diseases group (ANZPID) in using antiretroviral therapy in children with chronic HIV.
All children presenting following a potential HIV exposure should be immediately assessed for PEP, ideally in conjunction with a paediatric infectious diseases specialist. Potential HIV exposures include following alleged sexual assault, human bites and splash injuries. Parents should ideally be involved in discussions regarding the management of their children, especially if the child is younger than 16 years. There may be situations between ages 14 and 16 years where it is appropriate not to engage parents in these discussions, such as if care and protection issues exist or if a qualified physician deems the child to be Gillick competent.
Mandatory notifications to the relevant authority vary between Australian jurisdictions. Further information can be found for each jurisdiction in the Federal Government’s Reporting child abuse and neglect information sheet for service providers.
Among minors engaging in consensual HIV risk behaviours presenting for PEP, consideration should be given to the immediate transition to PrEP following completion of the 28-day PEP course (see section: People who are transitioning from PEP to PrEP). Inappropriate administration of PEP in cases where it is not required is costly, increases the risk of medication-related adverse events, and can increase the stress experienced by an acutely traumatised child.
All children younger than 16 years who qualify for HIV PEP are recommended to receive combination therapy with three drugs. This strategy differs from the risk-stratified approach used in adults, where two or three drugs may be considered depending on the risk-exposure event. A three-drug regimen is routinely recommended in children because observational data support a higher risk in younger age groups. The heightened risk is postulated to be due to the frequent presence of anogenital trauma, repeated episodes of assault by the same HIV-positive perpetrator, and thinner prepubertal vaginal mucosa and cervical ectopy.114 As for adults, it is recommended that the full 28-day PEP course be provided at the time of initial presentation.50
