Highlighting advances on clinical management of pediatric HIV

Introduction: Pediatric HIV remains a major global health challenge, with 1.4 million children living with HIV and persistent gaps in diagnosis, treatment coverage, and viral suppression. Despite increasing alignment between pediatric and adult guidelines toward rapid antiretroviral therapy (ART) initiation and integrase inhibitor (INSTI)-based regimens, many children remain unsuppressed and at risk of disease progression and drug resistance. Areas covered: This review summarizes current evidence on when to start ART, how to select and optimize regimens, and the evolving burden of antiretroviral resistance in children and adolescents. It also examines major comorbidities (including malnutrition, metabolic complications, bone disease, and neurocognitive impairment) and their interaction with lifelong ART. Practical aspects of care are discussed, including baseline assessment, virological and immunological monitoring, and strategies to support adherence and retention. Finally, we outline emerging and pipeline agents and their potential role in the future management of pediatric HIV. Expert opinion: Achieving durable viral suppression in children and adolescents requires earlier diagnosis, optimized child-friendly regimens, routine resistance testing, and integrated management of comorbidities. Key priorities include pediatric evaluation of long-acting and novel agents, development of improved immunologic and virologic markers, and scalable approaches to strengthen engagement in care and reduce global inequities.