Thousands of children benefit from newer HIV treatment
South Africa has taken a significant step in paediatric HIV care with the introduction of a child-friendly version of the antiretroviral drug dolutegravir in 2022. This rollout has marked a turning point in the management of HIV for children aged one to four, significantly improving treatment adherence and viral suppression rates.
Dolutegravir for children: a new standard
A child-friendly formulation of dolutegravir was formally included in South Africa’s HIV treatment guidelines in 2023. According to new estimates, most children aged one to four living with HIV have now been transitioned to this effective regimen.
The potent antiretroviral drug dolutegravir has long been the backbone of South Africa’s HIV treatment programme. Initially introduced in the ARV tender in 2019, dolutegravir has been rolled out gradually across the public health sector, with over 4.7 million adults already on treatment containing the drug by 2023.
The introduction of a child-friendly version in 2022, followed by the inclusion of a regimen of abacavir, lamivudine, and dolutegravir (ALD) in the 2023 treatment guidelines, has opened access to this highly effective treatment for younger patients.
Massive switch to dolutegravir
Dr Ahmad Haeri Mazanderani, joint researcher at Wits University and the National Institute for Communicable Diseases (NICD), reported that the number of children on dolutegravir-based regimens has increased dramatically since 2023.
In June 2023, only 8% of children aged one to four were on dolutegravir, while 92% were on older regimens. By June 2025, the figures had flipped, with 94% of children in this age group now receiving dolutegravir, leaving just 6% on non-dolutegravir treatments.
These figures, derived from the National Health Laboratory Service, the Thembisa model, and TIER.Net data, indicate a near-complete transition to child-friendly dolutegravir for one-to-four-year-olds.
Improved viral suppression
A key indicator of treatment success is viral suppression, which shows how effectively HIV is controlled in the body. Since 2023, the increase in dolutegravir use among young children has corresponded with improved viral suppression rates.
Rolling 12-month data indicate that viral suppression in children aged one to four rose from 58% in June 2023 to 76% in June 2025. Using a stricter threshold of 50 copies/ml, suppression rates increased from 34% to 54% over the same period.
Notably, girls consistently achieved higher suppression rates than boys, with a 3% advantage under the 1,000 copies/ml threshold and a 7% advantage at 50 copies/ml. Despite these gains, rates remain below the UNAIDS third 95 target, which aims for 95% of children on treatment to achieve viral suppression.
Challenges and room for improvement
Experts highlight that younger children face higher risks of virologic failure due to factors such as low BMI, low CD4 counts at treatment initiation, and complex social circumstances. Dr Moherndran Archary, a paediatric infectious diseases specialist, notes that inconsistent caregiving, difficult medication regimens, and multiple clinic visits can contribute to treatment challenges.
Dosing details and regimen simplification
Treating children with HIV is more complex than adult treatment due to weight-based dosing and varying formulations. Children under 10 years and weighing less than 30kg are dosed according to WHO weight bands. Those older than 10 and above 30kg typically receive adult TLD (tenofovir, lamivudine, dolutegravir).
Currently, children over four weeks and above 3kg are taking the ALD regimen: abacavir/lamivudine tablets plus dispersible dolutegravir tablets. For example, a 10kg child would take two tablets of each, dissolved in water for easy consumption.
Previously, children relied on multi-drug regimens such as abacavir/lamivudine combined with lopinavir/ritonavir, which were poorly tolerated. The new paediatric ALD formulation simplifies administration and improves adherence.
Future directions in paediatric HIV treatment
Experts anticipate further improvements as the paediatric ALD formulation becomes widely available, replacing older multi-tablet regimens. Long-acting ARV treatments, such as cabotegravir and rilpivirine injections, are also under study for children aged two to 12 years, offering additional treatment options in the future.
The rollout of child-friendly dolutegravir demonstrates South Africa’s commitment to improving paediatric HIV outcomes, but experts agree that continued monitoring, simplified regimens, and community support are essential to reach national and international viral suppression targets.
Conclusion
The child-friendly dolutegravir rollout has had a substantial impact on paediatric HIV treatment in South Africa. By improving access, adherence, and viral suppression, it represents a significant step forward in the fight against HIV among children. However, challenges remain, and continued innovation and support are required to ensure all children living with HIV can achieve optimal health outcomes.
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