Therapeutic Drug Monitoring in Pediatric HIV Treatment

Therapeutic drug monitoring (TDM) in children living with HIV is an evolving strategy to tailor antiretroviral therapy and improve long-term outcomes. Age-related changes in drug absorption, distribution, metabolism and excretion create wide inter-individual variability in antiretroviral exposure, with sub-therapeutic levels risking virological failure and supra-therapeutic levels predisposing to toxicity. In paediatric populations, weight-band dosing and formulations often derive from adult data, leaving younger children particularly vulnerable to under- or over-dosing. TDM uses quantitative measurement of drug concentrations in biological fluids to guide dose adjustments, optimise adherence interventions and prevent the emergence of resistance. In resource-limited settings, practical barriers include limited laboratory capacity, challenges in obtaining trough samples and high costs of instrumentation. Recent advances in micro-sampling, point-of-care assays and model-informed precision dosing are starting to bridge these gaps, enabling clinicians to individualise regimens for infants, children and adolescents. As paediatric HIV treatment scales up globally, integration of TDM into routine care promises to enhance safety, sustain virological suppression and support the roll-out of novel antiretroviral agents in diverse settings.

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Therapeutic Drug Monitoring in Pediatric HIV Treatment publication trend

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Technical terms

Therapeutic drug monitoring (TDM): The practice of measuring specific drug concentrations in biological fluids to guide individual dose adjustments and optimise therapeutic efficacy while minimising toxicity.

Pharmacokinetics (PK): The study of how a drug is absorbed, distributed, metabolised and excreted by the body, often summarised by parameters such as clearance, half-life and area under the concentration–time curve.

Lead-in period: An initial phase of antiretroviral therapy during which a reduced or staggered dosing regimen is used to mitigate adverse effects or auto-induction of metabolism.

Virological failure: The inability to maintain or achieve suppression of viral replication, typically defined by a persistent increase in HIV RNA above a specified threshold despite therapy.

High-performance liquid chromatography (HPLC): A laboratory technique that separates, identifies and quantifies components in a mixture, widely employed to measure antiretroviral drug levels in plasma or other matrices.

References

1. Sub-therapeutic nevirapine concentration during antiretroviral treatment initiation among children living with HIV: Implications for therapeutic drug monitoring. PLOS ONE (2017).
2. Therapeutic drug monitoring of nevirapine in saliva in Uganda using high performance liquid chromatography and a low cost thin-layer chromatography technique. BMC Infectious Diseases (2014).
3. Antiretroviral concentration measurements as an additional tool to manage virologic failure in resource limited settings: a case control study. AIDS Research and Therapy (2019).