Exploring how multi-criteria decision-making theory is transforming HIV post-exposure prophylaxis for children through systematic, evidence-based approaches.
Imagine a pediatrician facing a difficult decision: a two-year-old child may have been exposed to HIV. The doctor must quickly choose the best preventive treatment from multiple options, each with different benefits and limitations. Time is critical—treatment must begin within 72 hours to be effective 1 . This high-stakes scenario occurs regularly in clinics worldwide, and the complex decision-making process behind it is being transformed by an innovative approach called multi-criteria decision making (MCDM).
Children newly infected with HIV each day in 2024 according to WHO estimates 7
Hours maximum window for effective post-exposure prophylaxis initiation 1
For children potentially exposed to HIV, every moment counts. The World Health Organization reports that approximately 712 children became newly infected with HIV each day in 2024 7 . While post-exposure prophylaxis (PEP) can prevent HIV infection after exposure, determining the optimal regimen for children involves weighing numerous medical factors. The emerging application of MCDM theory represents a revolutionary approach to these critical decisions, potentially saving thousands of young lives through more systematic, evidence-based treatment selection.
Post-exposure prophylaxis (PEP) involves using antiretroviral medications to prevent HIV establishment in someone without HIV after a potential exposure. For PEP to be effective, treatment must begin as soon as possible—ideally within 24 hours and never beyond 72 hours after exposure 1 . The recommended course involves taking medication daily for 28 days 5 .
Pediatric HIV PEP presents unique challenges. Children are not simply small adults—their developing bodies process medications differently, and formulations must account for weight, age, and ability to swallow pills. Dosing regimens for children under 40 kg vary significantly, often requiring specialized formulations like liquid solutions or dissolvable tablets 8 .
| Regimen | Age/Weight Guidelines | Administration |
|---|---|---|
| Bictegravir/TAF/FTC (Biktarvy) | ≥14 kg to <25 kg | 1 tablet once daily (may be split) |
| Bictegravir/TAF/FTC (Biktarvy) | ≥25 kg | 1 tablet once daily |
| TDF + FTC + Raltegravir | ≥2 years and/or cannot swallow tablets | Multiple formulations |
| Zidovudine + Lamivudine + Raltegravir | 4 weeks to <2 years | Oral solutions 8 |
Multi-criteria decision making (MCDM) is a systematic approach to evaluating complex options against multiple, often competing, criteria. In healthcare, MCDM helps structure decisions that involve weighing clinical effectiveness against practical considerations like cost, availability, and patient preferences.
Traditional medical decision-making often focuses primarily on clinical effectiveness. MCDM expands this view by incorporating diverse stakeholder perspectives and multiple decision criteria simultaneously. This approach acknowledges that real-world healthcare decisions must balance scientific evidence with ethical considerations, resource constraints, and patient values 2 .
Systematically balances clinical evidence with practical constraints and patient preferences
A groundbreaking study in Thailand demonstrated how MCDM could transform HIV policy decisions. Researchers used this approach to prioritize 40 different HIV interventions, including prevention, treatment, and care programs 2 .
Three key groups were included—policy makers, people living with HIV/AIDS (PLWHA), and village health volunteers (VHVs)
Through group discussions, stakeholders identified key decision criteria including target population, gender, intervention type, effectiveness, and quality of evidence
Researchers scored each of the 40 interventions against the selected criteria
Using a statistical model, interventions were ranked based on their probability of selection by each stakeholder group
Stakeholders discussed and refined the rankings, considering additional factors
The results revealed fascinating differences in priorities among stakeholder groups:
Prioritized interventions for high-risk groups like men who have sex with men, injecting drug users, and female sex workers 2
Preferred programs targeting youth or the general population 2
Gave relatively equal priority to all interventions 2
| Research Tool | Function/Application | Significance in HIV Research |
|---|---|---|
| Topological Indices | Numerical descriptors of molecular structure | Predict drug efficacy and properties without laboratory testing 6 |
| Quantitative Structure-Property Relationship (QSPR) | Mathematical models linking structure to properties | Enable computer-based drug optimization and screening |
| Degree-Based Graph Invariants | Analyze molecular bonds and connectivity | Help understand how drug structure affects biological activity 6 |
| Chemical Graph Theory | Represent molecules as mathematical graphs | Facilitate analysis of molecular structure and properties |
The field of HIV prevention is evolving rapidly, with new technologies and approaches offering hope for better outcomes for children. Long-acting injectable medications represent a particularly promising development, potentially overcoming adherence challenges associated with daily pills 4 .
Increase in biomedical prevention coverage when choice is offered compared to standard approaches in Kenya and Uganda 4
Integrating MCDM algorithms into electronic health systems
For healthcare providers on shared decision-making
Collection to inform criteria weighting
For different resource settings
The 2025 International Workshop on Pediatrics & HIV highlighted ongoing research into newer antiretroviral formulations and prevention strategies specifically for children 3 . As these innovations emerge, MCDM approaches will become increasingly valuable for determining how best to incorporate them into clinical practice.
The application of multi-criteria decision-making theory to pediatric HIV PEP represents more than just a technical improvement—it embodies a fundamental shift toward more systematic, transparent, and patient-centered healthcare decisions. By explicitly acknowledging the multiple factors that influence treatment success, MCDM helps align medical interventions with real-world constraints and patient needs.
For the youngest and most vulnerable among us, this approach offers the promise of prevention strategies that are not only clinically effective but also practical, accessible, and acceptable. As research continues to refine both HIV medications and decision-making processes, we move closer to a future where no child need face the burden of HIV.
The fight against pediatric HIV requires every tool at our disposal—from advanced antiretrovirals to sophisticated decision frameworks. By marrying medical science with decision science, we create a more powerful shield against HIV, one that protects children more effectively and equitably than ever before.