Substituting lopinavir/ritonavir with efavirenz in children on stable ART

HIV Pediatrics WorkshopPolly Clayden, HIV i-Base

Virologic outcomes in children who were suppressed on lopinavir/ritonavir (LPV/r)-based ART and switched to efavirenz (EFV) were no worse than for those who remained on LPV/r, in a South African retrospective cohort study.

These findings from the IeDEA cohort were presented at the 7th International Workshop on HIV Pediatrics in Vancouver.

In 2013 World Health Organisation (WHO) guidelines added the option to substitute LPV/r with EFV in children who had started with LPV/r-based ART and had sustained virologic suppression. The evidence for this recommendation was mainly from the NEVEREST studies.

The IeDEA study compared outcomes between virologically suppressed children aged three years and above who switched to EFV or stayed on LPV/r in a routine clinical setting.

Of 690 children, 36 substituted EFV at a median of 44.1 months old. The median follow up time was 25.8 months (15 to 34.2) and 24.4 months (18.1 to 31.7) in the substitution and stay groups respectively.

At ART initiation, the children in the two groups were well matched, for age, CD4 percentage, weight-for-age z-score, WHO stage and viral load and at 42 months.

Remaining on LPV/r (stay group) was negatively associated with viral blip (an isolated viral load result >1000 copies/mL that returned to <400 copies/mL at next measurement) at 42 months. Blips occurred in 318 (48.6%) children in the stay group compared with 10 (27.8%) in the substitution group, p=0.015.

Factors associated with EFV substitution included: favourable clinical response to ART, adjusted OR per 1 weight-for-age z-score increase 1.34 (95% CI:0.96 to 1.80); and viral blips adjusted OR 0.34 (95% CI: 0.15 to 0.79).


Clearly the success of this strategy depends on access to viral load testing for widespread implementation.


  1. Reichmuth K et al. Virologic outcomes of children switched from lopinavir/ritonavir to efavirenz-based treatment: a retrospective cohort study. 7th International Workshop on HIV Paediatrics, 17-18 July, Vancouver, Canada. Oral abstract 1.
  2. Bienczak et al. The effect of systematic exposure to efavirenz, sex and age on the risk of virological non-suppression in HIV-infected African children. 7th International Workshop on HIV Pediatrics, 17-18 July, Vancouver, Canada. Oral abstract 2.

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