High Burdens of Drug Resistance Found in Children With HIV

Treatment for children with HIV can be challenging, in part due to the possibility of drug resistance when attempting to target the virus. A failure to prevent the transmission of HIV from mother to child was found to lead to pretreatment drug resistance (PDR) and acquired drug resistance (ADR) in children included in a review published in Open Forum Infectious Diseases.¹

Transmission from women to their child often led to both pretreatment and acquired drug resistance to treatments for HIV | Image credit: ArvStd - stock.adobe.com

The rate of transmission of HIV from a mother to her child without intervention ranges from 15% to 45% when taking into account the time of pregnancy, labor, and breastfeeding.² With intervention, these numbers can be reduced to less than 2% in the US.³ However, children still contract HIV despite these interventions, and access to treatment remains limited. This review aimed to assess the prevalence of PDR and ADR in children living with HIV in the past decade.

PubMed/MEDLINE, ScienceDirect, Google Scholar, gray literature databases, and African journals online were searched for relevant studies. Studies were included in the review if they included participants aged 0 to 15 years; were involved in interventions to prevent transmission from mother to child, with those with no exposure from their parent acting as the comparison group; were published between 2010 and early 2014 and were published in English or French; and were randomized, nonrandomized, cohort, or cross-sectional studies. Pooled prevalence of PDR and ADR in children with HIV and being treated for HIV-1 acted as the primary outcome. Case reports, letters, comments, reviews, and meta-analyses were excluded from the review.

Study design, sampling method, sampling period, age, gender, sample type, sample size, rate of drug resistance, and exposure to parent-to-child HIV transmission were all extracted from the studies included in the review. Use of antiretroviral therapy (ART) was also assessed.

There were 325 studies including 9973 children that were included in the review; 52.5% of the participants were male. Cross-sectional studies made up the majority of the studies (38.46%), followed by cohort studies (17.9%).

A total of 5884 participants had data regarding PDR available. There were 3836 participants who had data on exposure to HIV from their parent, of whom 66.36% were exposed to prophylaxis to prevent transmission. Overall prevalence of PDR was 31.94%, with 43.23% of those exposed to prophylaxis having PDR compared with 19.40% who had no exposure. Sub-Saharan African children had a prevalence of PDR of 39.13% compared with 22.56% in other regions.

A total of 4140 children had data on ADR. Prevalence of ADR was higher at 61.43% in those who had virological failure. Children in sub-Saharan Africa had a prevalence of ADR totaling 67.58% compared with 18.75% in other countries.

Nonnucleoside reverse transcriptase inhibitors (NNRTI) were the driver of PDR in children with HIV (OR, 2.46; 95% CI, 2.12-7.86). The prevalence of PDR in those using NNRTIs was 28.38% compared with 12.06% in those using nucleoside reverse transcriptase inhibitors and 5.51% in those using protease inhibitors. NNRTI resistance was also the dominant reason for ADR by drug class (OR, 3.84%; 95% CI, 3.36-4.38) with a pooled prevalence of 65.17%.

The authors concluded that there was a high prevalence of PDR and ADR in children living with HIV, pointing to NNRTIs as a particular source of drug resistance for these populations.

“Overall, the threat of [drug resistance] in children calls for newer [ART] prophylactic and therapeutic strategies [and] personalized clinical management, while advocating for the development of newer pediatric [ARTs] to fast-track the elimination of AIDS in this vulnerable population,” the authors wrote.

References

1. Fokam J, Da’e AC, Yagai B, et al. HIV-1 drug resistance in children and implications for pediatric treatment strategies: a systematic review and meta-analysis. Open Forum Infect Dis. 2025;12(7):ofaf378. doi:10.1093/ofid/ofaf378

2. Mother-to-child transmission of HIV. World Health Organization. Accessed July 23, 2025. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/prevention/mother-to-child-transmission-of-hiv

3. Perinatal (mother-to-child) HIV transmission. Minnesota Department of Health. Updated October 20, 2022. Accessed July 23, 2025. https://www.health.state.mn.us/diseases/hiv/prevention/perinatal.html