Short-term risk of disease progression in HIV-1-infected children receiving no antiretroviral therapy or zidovudine monotherapy: a meta-analysis

Current CD4 cell count and the short-term risk of AIDS and death before the availability of effective antiretroviral therapy in HIV-infected children and adults

BACKGROUND

Currently, there are no comparable estimates of the short-term risk of disease progression in the absence of effective antiretroviral therapy for human immunodeficiency virus (HIV)-infected adults and children.

METHODS

A joint analysis of 2 large studies of children with vertically acquired HIV infection (the HIV Paediatric Prognostic Markers Collaborative Study) and adults with seroconversion (the CASCADE [Concerted Action on Sero-Conversion to AIDS and Death in Europe] collaboration) was conducted. Follow-up was censored at the end of 1995, before the introduction of combination antiretroviral therapy. The incidence rates of death and AIDS or death (AIDS/death) were estimated on the basis of age and current CD4 cell count.

RESULTS

A total of 1260 deaths (over 20,500 person-years of follow-up) and 1894 initial AIDS events (over 17,200 person-years of follow-up) were observed among 6741 patients (3244 children [i.e., patients < or =15 years of age] and 3497 adults). Young children (age, <5 years) experienced high morbidity and mortality rates. After adjustment for the CD4 cell count, the effect of age on disease progression was not significant among older children, whereas the risk increased markedly in association with increasing age among adults. Death rates were similar among older children and adults aged approximately 20 years, as were the rates of progression to AIDS/death when cases of serious recurrent bacterial infection, which has a more restrictive case definition in adults, were excluded.

CONCLUSIONS

Similar CD4 cell count criteria for initiation of antiretroviral therapy can be applied to adults and children > or = 5 years of age.

When should children with HIV infection be started on antiretroviral therapy?

BACKGROUND TO THE DEBATE

The advent of highly active antiretroviral therapy (HAART) dramatically improved the prognosis for both adults and children infected with HIV who had access to treatment. However, the optimal timing for initiating treatment remains controversial, particularly in children. This debate lays out the case for deferred treatment against the case for early initiation of HAART in children.

Markers for predicting mortality in untreated HIV-infected children in resource-limited settings: a meta-analysis

OBJECTIVES

To evaluate the prognostic value of selected laboratory and growth markers on the short-term risk of mortality in untreated HIV-infected children in resource-limited settings.

DESIGN

A meta-analysis of individual longitudinal data on children aged 12 months onwards from 10 studies (nine African, one Brazilian in the 3Cs4kids collaboration).

METHODS

The risk of death within 12 months based on age and the most recent measurements of laboratory and growth markers was estimated using Poisson regression models, adjusted for cotrimoxazole prophylaxis use and study effects.

RESULTS

A total of 2510 children contributed 357 deaths during 3769 child-years-at-risk, with 81% follow-up occurring after start of cotrimoxazole. At first measurement, median age was 4.0 years (interquartile range, 2.2-7.0 years), median CD4% was 15% and weight-for-age z-score -1.9. CD4% and CD4 cell count were the strongest predictors of mortality, followed by weight-for-age and haemoglobin. After adjusting for these markers, the effects of total lymphocyte count and BMI-for-age were relatively small. Young children who were both severely malnourished and anaemic had high mortality regardless of CD4 values, particularly those aged 1-2 years. By contrast, high CD4% or CD4 cell count values predicted low mortality level amongst either children older than 5 years or those younger with neither severe malnutrition nor anaemia.

CONCLUSIONS

CD4 measurements are the most important indicator of mortality and wider access to affordable tests is needed in resource-limited settings. Evaluation of antiretroviral initiation in children also needs to consider weight-for-age and haemoglobin. Prevention and treatment of malnutrition and anaemia is integral to HIV paediatric care and could improve survival.

HIV-infected children living in Central Africa have low persistence of antibodies to vaccines used in the Expanded Program on Immunization

Background

The Expanded Program on Immunization (EPI) is the most cost-effective measures to control vaccine-preventable diseases. Currently, the EPI schedule is similar for HIV-infected children; the introduction of antiretroviral therapy (ART) should considerably prolong their life expectancy.

Methods and Principal Findings

To evaluate the persistence of antibodies to the EPI vaccines in HIV-infected and HIV-exposed uninfected children who previously received these vaccines in routine clinical practice, we conducted a cross-sectional study of children, aged 18 to 36 months, born to HIV-infected mothers and living in Central Africa. We tested blood samples for antibodies to the combined diphtheria, tetanus, and whole-cell pertussis (DTwP), the measles and the oral polio (OPV) vaccines. We enrolled 51 HIV-infected children of whom 33 were receiving ART, and 78 HIV-uninfected children born to HIV-infected women. A lower proportion of HIV-infected children than uninfected children had antibodies to the tested antigens with the exception of the OPV types 1 and 2. This difference was substantial for the measles vaccine (20% of the HIV-infected children and 56% of the HIV-exposed uninfected children, p<0.0001). We observed a high risk of low antibody levels for all EPI vaccines, except OPV types 1 and 2, in HIV-infected children with severe immunodeficiency (CD4⁺ T cells <25%).

Conclusions and Significance

Children were examined at a time when their antibody concentrations to EPI vaccines would have still not undergone significant decay. However, we showed that the antibody concentrations were lowered in HIV-infected children. Moreover, antibody concentration after a single dose of the measles vaccine was substantially lower than expected, particularly low in HIV-infected children with low CD4⁺ T cell counts. This study supports the need for a second dose of the measles vaccine and for a booster dose of the DTwP and OPV vaccines to maintain the antibody concentrations in HIV-infected and HIV-exposed uninfected children.

Natural killer cells in perinatally HIV-1-infected children exhibit less degranulation compared to HIV-1-exposed uninfected children and their expression of KIR2DL3, NKG2C, and NKp46 correlates with disease severity

NK cells play an integral role in the innate immune response by targeting virally infected and transformed cells with direct killing and providing help to adaptive responses through cytokine secretion. Whereas recent studies have focused on NK cells in HIV-1-infected adults, the role of NK cells in perinatally HIV-1-infected children is less studied. Using multiparametric flow cytometric analysis, we assessed the number, phenotype, and function of NK cell subsets in the peripheral blood of perinatally HIV-1-infected children on highly active antiretroviral therapy and compared them to perinatally exposed but uninfected children. We observed an increased frequency of NK cells expressing inhibitory killer Ig-like receptors in infected children. This difference existed despite comparable levels of total NK cells and NK cell subpopulations between the two groups. Additionally, NK cell subsets from infected children expressed, with and without stimulation, significantly lower levels of the degranulation marker CD107, which correlates with NK cell cytotoxicity. Lastly, increased expression of KIR2DL3, NKG2C, and NKp46 on NK cells correlated with decreased CD4+ T-lymphocyte percentage, an indicator of disease severity in HIV-1- infected children. Taken together, these results show that HIV-1-infected children retain a large population of cytotoxically dysfunctional NK cells relative to perinatally exposed uninfected children. This reduced function appears concurrently with distinct NK cell surface receptor expression and is associated with a loss of CD4+ T cells. This finding suggests that NK cells may have an important role in HIV-1 disease pathogenesis in HIV-1-infected children.

Treatment of pediatric HIV infection

HIV-infected children require a peculiar management when compared to infected adults. Antiretroviral therapy has been quite well adapted to children, but new studies are needed to answer many unsolved questions, such as when to start therapy in asymptomatic infected children. Recently, several guidelines have been updated. In this review, we compare these recommendations together with the latest studies concerning the treatment of HIV in children. A triple-drug combination therapy based either on nonnucleoside reverse transcriptase inhibitors or protease inhibitors is the recommended initial therapy. After treatment failure, a second-line therapy should be based on switching between these two regimens. Antiretroviral therapy should be managed by an expert in pediatric and adolescent HIV infection. The importance of children's adherence to therapy is a crucial point, particularly in adolescents.

Long-term nonprogression of HIV infection in children: evaluation of the ANRS prospective French Pediatric Cohort

BACKGROUND

Some children who are infected with human immunodeficiency virus type 1 (HIV-1) during the perinatal period remain asymptomatic for very long periods in the absence of antiretroviral treatment, as is the case for some adults. Our objective was to estimate the proportion of children who developed neither symptoms nor major immunological perturbations to the age of > or = 10 years in a prospective cohort of infected children who had been observed since birth.

METHODS

The ongoing prospective French Pediatric Cohort includes 568 HIV-1-infected children. Here, we report the follow-up data for all 348 HIV-1-infected children who were born before 1 January 1994. Children with long-term nonprogression of infection (LTNPs) were defined as HIV-1-infected children who had been observed for at least 10 years, never received antiretroviral treatment other than zidovudine monotherapy, never developed symptoms of Centers for Disease Control and Prevention clinical category C or B, and had a CD4+ cell percentage of < 25% no more than once during follow-up. Other definitions were compared.

RESULTS

The Kaplan-Meier estimate of long-term nonprogression was 2.4% (95% confidence interval, 1.1%-4.6%) at 10 years of age, and 7 children were classified as LTNPs. The Kaplan-Meier estimates decreased slightly with age, to 1.8% at 12 years of age and 1.4% at 14 years of age. Plasma HIV-1 replication rates were low (< 1000 copies RNA/mL) for 2 of the 7 LTNPs at the age of 10 years (0.6% of the total denominator). None of the routinely measured maternal or perinatal markers were significantly linked to long-term nonprogression, with the exception of the mother's Centers for Disease Control and Prevention clinical category at the time of delivery.

CONCLUSIONS

Approximately 2% of children who were infected during the perinatal period displayed no immunological or clinical progression by the age of 10 years. This figure is close to that reported for adults in studies that have used similar definitions.

International perspectives, progress, and future challenges of paediatric HIV infection

Paediatric HIV infection is a growing health challenge worldwide, with an estimated 1500 new infections every day. In developed countries, well established prevention programmes keep mother-to-child transmission rates at less than 2%. However, in developing countries, where transmission rates are 25-40%, interventions are available to only 5-10% of women. Children with untreated natural infection progress rapidly to disease, especially in resource-poor settings where mortality is greater than 50% by 2 years of age. As in adult infection, antiretroviral therapy has the potential to rewrite the natural history of HIV, but is accessible only to a small number of children needing therapy. We focus on the clinical and immunological features of HIV that are specific to paediatric infection, and the formidable challenges ahead to ensure that all children worldwide have access to interventions that have proved successful in developed countries.

Acute human immunodeficiency virus infection in a breast-fed infant in New York City

Acute human immunodeficiency virus (HIV) infection in a breast-fed infant is a rare diagnosis in developed countries. We present a six-month old girl with postnatally acquired HIV infection complicated by Pneumocystis jéroveci pneumonia, cytomegalovirus pneumonitis and encephalopathy. Her mother had tested negative for HIV during pregnancy. Children infected by mothers during an acute seroconversion may have more rapid disease progression.

Treatment Outcomes Stratified by Baseline Immunological Status among Young Children Receiving Nonnucleoside Reverse-Transcriptase Inhibitor-Based Antiretroviral Therapy in Resource-Limited Settings

A study of 568 children aged <5 years who commenced nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings revealed good early outcomes. After 12 months of antiretroviral therapy, survival probability was 0.89 (95% confidence interval, 0.86-0.92), with no significant difference among children stratified on the basis of baseline immunological levels; 62% attained a CD4 cell percentage >25%, and 7% continued to have a CD4 cell percentage <15%.

Plasma Concentrations of the HIV-Protease Inhibitor Lopinavir are Suboptimal in Children Aged 2 Years and Below

Background

Lopinavir/ritonavir (LPV/r) has been licensed for the treatment of HIV-infected children >6 months in the US and >2 years in the EU. Limited LPV paediatric pharmacokinetic data are available. We studied LPV pharmacokinetics to determine whether the recommended dose (230/57.5 mg/m2 twice daily) results in optimal LPV exposure in all age groups. Virological efficacy was a secondary objective.

Methods

HIV-1-infected children who started treatment with LPV/r and two nucleoside reverse transcriptase inhibitors underwent a 12-h pharmacokinetic curve. LPV plasma concentrations were determined with a validated HPLC method with UV detection. If Cmin was <1.0 mg/l LPV/r dose was increased by 33%. Plasma trough levels were drawn subsequently. HIV-1 RNA was followed-up until week 48.

Results

A total of 23 children were included (seven girls; 16 boys), with a median (range) age of 5.6 (0.4–13.2) years. Mean (±SD) AUC0–12h, Cmax and Cmin of LPV were 75.3 (±33.7) mg/l.h, 9.33 (±3.27) mg/l and 3.68 (±2.48) mg/l, respectively, which is similar to previously published data. Interindividual variability was large. Cmin was inadequate in 7/23 children. Significantly more children <2 years had inadequate Cmin compared with children >2 years. Dose increase to ±300/75 mg/m2 LPV/r led to Cmin >1.0 mg/l. The studied regimen provided excellent viral suppression for naive and pretreated patients.

Conclusions

Mean LPV pharmacokinetic parameters in these HIV-infected children are similar to published data, but exposure is significantly reduced in children <2 years. Prospective pharmacokinetic studies using 300/75 mg/m2 LPV/r in this age population are urgently warranted.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.

Recommendations in pediatric antiretroviral therapy

The pathogenesis of HIV infection and the general principles of therapy are the same for HIV-infected adults, adolescents, children and infants. However, antiretroviral treatment of HIV infection in pediatrics requires the consideration of a number of factors specific to its population, including differences in drug pharmacokinetics and the use of virologic and immunologic markers, as well as age-related adherence issues. This review summarizes the text of the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, which was updated in October 2006. The guidelines are the work of the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children, a group of the Office of AIDS Research Advisory Council of the National Institutes of Health, which reviews new data on an ongoing basis and provides regular updates to the guidelines. As these guidelines were developed for the US, they may not be applicable in other countries. This summary does not attempt to place the Working Group guidelines in the context of international guidelines, nor does it attempt to detail the use of antiretroviral medication in the prevention of perinatal transmission of HIV, such as addressing the use of zidovudine versus single-dose nevirapine.

[New challenges in therapeutic management of human immunodeficiency virus-infected children]

More than 2 millions of children worldwide are HIV-infected. Recently, the HIV related mortality and morbidity has dramatically decreased due to the use of antiretroviral multitherapies in the HIV-infected children. However the therapeutic management of HIV-infected children is complex and may be complicated by socio-familial issues. Short and long term toxicity of antiretrovirals but also of HIV itself are of concern. Despite the good clinical and immunological results of antiretroviral multitherapies, virological failure may occur. Paediatric pharmacokinetic specificities and inadequate galenic presentation of drugs could lead to virological failure. However, the use of more potent drugs with more adapted presentation actually reduces this risk of failure. Prospective cohorts of HIV-infected children and new antiretroviral drugs paediatric evaluation are of key importance and can improve the paediatric therapeutic management. Finally, universal access to antiretroviral drugs in children, particularly in developing countries is the major actual and future challenge.

AN, Moncau JEC, Marcopito LF, Marques HHDS, Succi RCM, Della Negra M, Hearst N. AIDS by mother-to-child transmission: survival analysis of cases followed from 1983 to 2002 in different regions of Brazil

Antiretroviral therapy contributes to decreasing morbidity and mortality, and ultimately to increasing survival. In Brazil, there are regional differences in HIV epidemiology regarding pregnant women and children with HIV/AIDS. This study evaluates survival time after AIDS diagnosis in 914 children infected by mother-to-child transmission, reported between 1983 and 1998 and followed until 2002, in Brazil's five regions. Time between birth and HIV diagnosis decreased over the years, mainly in the South and Southeast Regions. There was a significant improvement in survival; more than 75% of cases were still living four years after diagnosis in the 1997-1998 group. This Brazilian study demonstrates that even with regional inequalities in health care infrastructure it is possible for a developing country to establish an effective system of universal and free access to antiretroviral therapy that produces a significant increase in survival for children with AIDS.

Varicella vaccination in HIV-1-infected children after immune reconstitution

BACKGROUND

HIV-1-infected children have an increased risk of severe chickenpox. However, vaccination is not recommended in severely immunocompromised children.

OBJECTIVE

Can the live-attenuated varicella zoster virus (VZV) Oka strain be safely and effectively given to HIV-1-infected children despite previously low CD4 T-cell counts?

METHODS

VZV vaccine was administered twice to 15 VZV-seronegative HIV-1-infected children when total lymphocyte counts were greater than 700 lymphocytes/microl, and six HIV-negative VZV-seronegative siblings. Weekly clinical follow-up and sampling were performed.

RESULTS

None of the children developed any clinical symptom or serious adverse reaction after immunization. Only nine (60%) of the HIV-1-infected children had VZV-specific antibodies after two immunizations, whereas 100% of the siblings seroconverted. Age at baseline was negatively correlated with the VZV IgG titre at 6 weeks after the second vaccination in HIV-1-infected children. VZV-specific antibody titres after two immunizations were at a similar level to those found after wild-type infection in non-vaccinated HIV-1-infected patients, but significantly lower than in HIV-negative siblings. Importantly, VZV-specific T-cell responses increased after vaccination and were comparable in both groups over time. Documented wild-type VZV contact in three vaccinated patients did not result in breakthrough infections.

CONCLUSION

VZV vaccination of previously immunocompromised HIV-1-infected children was safe. Vaccination induced specific immune responses in some of the vaccinated HIV-1-infected children, suggesting that previously immunocompromised individuals are protected against severe forms of varicella.

Considerations in the design of randomized controlled trials evaluating the optimal time to initiate antiretroviral therapy in previously untreated HIV-1-infected patients

PURPOSE OF REVIEW

This paper addresses design issues around 'when to start' trials in adults and children and in chronic and acute HIV infection. Issues for young children treated soon after birth and recently seroconverting adults differ, and are also discussed.

RECENT FINDINGS

No trials have been published addressing this question for combination antiretroviral therapy in chronic HIV infection, and the evidence base for guidelines has largely been derived from observational studies. The biases inherent in observational data and recent results from the adult SMART trial may have moved the level of equipoise from 'unstable certainty' (mitigating against randomization) to a renewed call for a very large clinical endpoint trial of when to start therapy in the era of highly active antiretroviral therapy. Older children could also be enrolled in such a trial, as the predictive value of CD4 cell count values in children over 5 years and young adults. In acute infection, ongoing trials in adults and children is similar considering strategies of early short-term combination antiretroviral therapy compared with deferred therapy. Although not strictly 'when to start trials', these approaches could reduce life-long exposure to antiretroviral therapy while maintaining clinical and immunological well being.

SUMMARY

Issues in the design of a future randomized trial of when to start antiretroviral therapy in chronic HIV infected adults and older children are discussed, while the role of early limited therapy in primary infection awaits results of ongoing trials.

Initiating highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children in Europe and the United States: comparing clinical practice to guidelines and literature evidence

Several guidelines are available to guide the initiation of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected children. The recommendations in these guidelines show significant variability. Because there is no well-established evidence on when to start HAART, it is left to the discretion of the pediatrician which guidelines to follow. We conducted a survey concerning the indications for starting antiretroviral therapy among pediatricians involved in the treatment of HIV-infected patients in Europe and the United States. We compared the results of this survey with the guidelines available at the time, the recently adapted guidelines and literature evidence. Our results indicate that in clinical practice HAART was initiated at higher viral loads and lower CD4 counts than recommended by the guidelines. American guidelines recommended and still recommend more aggressive treatment than the European guidelines, and this is reflected in clinical practice. Until recently all guidelines were based on long term risk analyses of progression to acquired immunodeficiency syndrome (AIDS) and death performed in cohort data. A recent short term risk analysis makes it possible to calculate the 6 or 12-month risk for progression to AIDS or death for an individual child. Because viral load and CD4 count are typically measured every 3 months, one can argue that it is clinically more relevant to base the decision of when to start HAART on the short term probability of disease progression. Guidelines in Europe are now based on this type of analysis. The American guidelines only adopted the thresholds for CD4 and viral load. The short term risk analysis also shows that the risk for developing AIDS varies markedly with age. This should be reflected in all guidelines. Determining the acceptable risk of disease progression is difficult and influenced by patient-, doctor- and culture-related factors. The controversy over whether or not to treat asymptomatic infants is unresolved as well. All infants have a very high risk of disease progression regardless of their viral load or CD4 count, but lifelong treatment with a potential for significant toxicities and risk of developing resistance is also not an appealing option. We recommend an attempt to achieve a consensus among the different working groups to reduce the number of different guidelines, which should be based on the literature evidence. Because all risk analyses are based on information from the pre-HAART era, a head-to-head trial comparing early versus deferred HAART would be useful. This may be difficult to accomplish. The first step could be an analysis of retrospective data from collaborative cohort data.

Diagnosis of pediatric human immunodeficiency virus infection in resource-constrained settings

The majority of children infected with human immunodeficiency virus live in resource-constrained settings and die without an established diagnosis. Definitive laboratory diagnosis in children younger than 12-18 months requires virologic testing; however, antibody testing is often the only option available. Antibody testing provides a definitive diagnosis in older children but is frequently not used. Children meeting clinical criteria should be treated regardless of availability of laboratory diagnoses.

Determinants of Survival Without Antiretroviral Therapy After Infancy in HIV-1-Infected Zambian Children in the CHAP Trial

BACKGROUND

There are few data on predictors of HIV progression in untreated children in resource-limited settings.

METHODS

Children with HIV Antibiotic Prophylaxis (CHAP) was a randomized trial comparing cotrimoxazole prophylaxis with placebo in HIV-infected Zambian children. The prognostic value of baseline characteristics was investigated using Cox models.

RESULTS

Five hundred fourteen children aged 1 to 14 (median 5.5) years contributed 607 years follow-up (maximum 2.6 years). Half were boys, and in 67%, the mother was the primary carer; at baseline, median CD4 percentage was 11% and weight was less than third percentile in 67%. One hundred sixty-five children died (27.2 per 100 years at risk; 95% confidence interval 23.3-31.6). Low weight-for-age, CD4 percentage, hemoglobin, mother as primary carer, current malnutrition, and previous hospital admissions for respiratory tract infections or recurrent severe bacterial infections were independent predictors of poorer survival, whereas oral candidiasis predicted poorer survival only when baseline CD4 percentage was not considered. Mortality rates per 100 child years of 44.5 (37.2-53.2), 14.7 (10.9-19.8), and 2.3 (0.3-16.7) were associated with new World Health Organization stages 4, 3, and 1/2, respectively, applied retrospectively; very low weight-for-age was the only staging feature for 42% of stage 4 children.

CONCLUSIONS

Malnutrition and hospitalizations for respiratory/bacterial infections predict mortality independent of immunosuppression, suggesting that they capture HIV- and non-HIV-related mortality, whereas oral candidiasis is a proxy for immunosuppression.

Correlation of CD4 count, CD4% and HIV viral load with clinical manifestations of HIV in infected Indian children

AIM

To correlate the absolute CD4 count, CD4% and HIV viral load with different clinical manifestations of HIV in antiretroviral-naive children.

SETTING

The paediatric and perinatal HIV clinic in a tertiary care hospital over a period of 4 years, from January 1999 to December 2003.

MATERIALS AND METHODS

A total of 92 highly active antiretroviral-naive, HIV-1-infected children were enrolled in a cross-sectional study. The clinical manifestations, age, sex and CDC classification of each patient were determined. CD4 count, CD4% and HIV-1 viral load were estimated at presentation and correlated with various clinical manifestations of HIV disease.

RESULTS

CD4% was higher in infants (p < 0.001) and lower in children over 5 years of age (p = 0.01). Boys had a higher absolute CD4 count than girls (769 +/- 517 vs 532 +/- 430 cells/mm3, p = 0.02). Patients with lymphadenopathy (n = 43) had a high CD4 count (840 +/- 487 cells/mm3, p = 0.01) whereas patients with HIV cardiomyopathy (n = 4) had low CD4 counts (mean 182 cells/mm3, p = 0.04). In patients with failure to thrive (n = 29), the CD4% was low (14 +/- 9%, p = 0.02) and HIV-1 viral load was high (mean 4.5 x 10(5) copies/ml, p = 0.03). CD4 count, CD4% and HIV viral load did not correlate with the stage of the disease as per the CDC classification.

CONCLUSION

HIV viral load, CD4 cell count and CD4% vary with age and disease complications in HIV-infected children. However, CD4 count, CD4% and viral load did not correlate with CDC classification.

Predictive value of absolute CD4 cell count for disease progression in untreated HIV-1-infected children

OBJECTIVES

To describe the relationship between absolute CD4 cell count and the short-term risk of disease progression in HIV-1-infected children.

DESIGN

A meta-analysis of individual longitudinal data on HIV-1-infected children enrolled in trials and cohort studies in Europe and the USA.

METHODS

The risks of progression to death and AIDS (or death) within 12 months, in terms of age and the most recent CD4 cell count, were estimated using parametric survival models. The analysis was restricted to measurements before the start of antiretroviral therapy except zidovudine monotherapy. The values of the absolute CD4 cell count and percentage predicting selected levels of disease progression risk were determined from this and previous models.

RESULTS

A total of 566 deaths was observed over 9128 person-years of follow-up, and 992 children progressed to AIDS or death over 7309 person-years of follow-up. In children older than 4 or 5 years, the estimated risk of disease progression increased sharply when the CD4 cell count fell below 200-300 cells/microl. As with other immunological markers, CD4 cell count was less prognostic in younger children. The CD4 cell count values predicting a 12-month risk of death of 2-5% and of AIDS of 5-10% were much more strongly influenced by age than equivalent CD4 cell percentage values.

CONCLUSION

This study suggests it may be appropriate to extend CD4 cell count criteria for initiating antiretroviral therapy in HIV-1-infected adults to children as young as 4 or 5 years. Monitoring by CD4 cell count in younger children is problematical because age is a highly influential variable.

Mortality in HIV-infected and uninfected children of HIV-infected and uninfected mothers in rural Uganda

OBJECTIVE

To estimate 2-year mortality rates in HIV-1-infected and uninfected infants born to HIV and HIV mothers.

METHODS

Data are from a prospective study in rural Rakai District, Uganda. Infant HIV status (determined by polymerase chain reaction) was evaluated at 1 to 6 weeks postpartum and during breast-feeding, and maternal HIV viral load and CD4 levels were measured at the postpartum visit. Multivariate Cox proportional hazards models and Kaplan-Meier survival analysis were used to assess survival of infants by maternal and infant HIV status and by quartiles of viral load. Log-rank tests were used to test the equality of survival functions.

RESULTS

Of the 4604 pregnant women, 16.9% were HIV, and the proportion of children infected was 20.9%. Median survival of HIV-infected infants was 23 months. Two-year child mortality rates were 128 of 1000 children born to HIV mothers, 165.5 of 1000 uninfected children born to HIV mothers, and 540.1 of 1000 HIV-infected children (P < 0.0001). Compared with children of HIV mothers, the hazard of child mortality was 2.04 (P < 0.001) if the mother was HIV and 3.78 (P < 0.001) if the infant was also infected. In the adjusted model, the highest quartiles of log10 HIV viral load in infants and mothers were associated with significantly increased hazard of child mortality (hazard ratio [HR] = 8.54 and HR = 2.50, respectively). Maternal CD4 counts <200 cells/mL were also significant predictors of child mortality (HR = 2.61). A total of 67.6% of HIV-infected children with viral loads above the median died by the age of 2 years and are in need of early antiretroviral therapy (ART).

CONCLUSIONS

More than half of HIV-infected infants died at less than 2 years of age. Therefore, ART may need to be initiated earlier in HIV-infected African children.

Outcomes for human immunodeficiency virus-1-infected infants in the United kingdom and Republic of Ireland in the era of effective antiretroviral therapy

BACKGROUND

There are few data about disease progression and response to antiretroviral therapy (ART) in vertically HIV-infected infants in the era of effective therapy.

DESIGN

Cohort study.

METHODS

We examined progression to acquired immunodeficiency syndrome (AIDS) and death over calendar time for infants reported to the National Study of HIV in Pregnancy and Childhood in the United Kingdom/Ireland. The use of ART and CD4 and HIV-1 RNA responses were assessed in a subset in the Collaborative HIV Pediatric Study.

RESULTS

Among 481 infants, mortality was lower in those born after 1997 (HR 0.30; P < 0.001), with no significant change in progression to AIDS. Of 174 infants born since 1997 in the Collaborative HIV Pediatric Study, 41 (24%) were followed from birth, 77 (44%) presented pre-AIDS and 56 (32%) presented with AIDS. Of 125 (72%) children on 3- or 4-drug ART by the age of 2 years, 59% had HIV-1 RNA <400 at 12 months; median CD4 percentage increased from 24% to 35%. Among 41 infants followed from birth, 12 progressed to AIDS (5 while ART naive) and 3 died; 1 of 10 infants initiating ART before 3 months of age progressed clinically.

CONCLUSION

Mortality in HIV-infected infants is significantly lower in the era of effective ART, but symptomatic disease rates remain high. Infrequent clinic attendance and poor compliance with cotrimoxazole prophylaxis and/or ART in infants born to diagnosed HIV-infected women and late presentation of infants identified after birth appear to be major contributors. Poor virologic response to ART during infancy is of concern because of increased likelihood of early development of resistance.

Differential Restoration of Myeloid and Plasmacytoid Dendritic Cells in HIV-1-Infected Children after Treatment with Highly Active Antiretroviral Therapy

Numerical and functional deficits in myeloid (mDC) and plasmacytoid dendritic cell (pDC) subsets have been found in both adult and pediatric HIV-1 carriers. Whether these impaired DC subsets can be restored after treatment with highly active antiretroviral therapy (HAART) is currently unknown, especially in HIV-1-infected children. In this report, we characterized mDC and pDC subsets in 18 HIV-1-infected children who received HAART treatment and compared them with those in 6 untreated HIV-1-infected children and 27 HIV-1-uninfected healthy children. Among children treated with HAART, 11 were found to suppress HIV-1 replication successfully below the detection limit (HAART-suppressed group) while the remaining 7 failed (HAART-failure group). In HAART-suppressed children, a gradual and complete restoration of the frequency and function of mDCs was observed while the recovery of pDCs was only partial. However, mDC and pDC subsets in HARRT failure children were indistinguishable from the HAART-naive infected children. We also found that mDC frequency and IFN-alpha-releasing capacity of pDC positively correlated with CD4 T cell percentages in all HIV-1-infected children. In HAART-naive children, the mDC frequency correlated the HIV-1-specific CTL frequency. Our findings suggest that HAART has a differential impact on the restoration of mDC and pDC subsets. These findings may help guide the development of HIV-1-specific immune therapy aimed at fully restoring host immune function in chronically HIV-1-infected children.

Long-Term Effects of Highly Active Antiretroviral Therapy in Pretreated, Vertically HIV Type 1-Infected Children: 6 Years of Follow-Up

BACKGROUND

Several studies of children with human immunodeficiency virus (HIV) type 1 infection have demonstrated sustained increases in CD4+ cell count, even when virological failure has occurred after receipt of highly active antiretroviral therapy (HAART), but these studies were of limited duration. Moreover, the CD4+ cell count threshold at which antiretroviral treatment should be initiated is still unsettled. The aim of this study was to define the long-term impact of HAART on CD4+ cell percentage and viral load according to CD4+ cell percentages before HAART was initiated.

METHODS

We conducted a retrospective study of 113 pretreated HIV-1-infected children stratified by pre-HAART CD4+ cell percentage (<5%, 5%-15%, 15%-25%, and >25%). The inclusion criteria were as follows: initiating HAART with a protease inhibitor, having 6 years of follow-up after starting HAART, having a CD4+ cell count or viral load recorded before initiation of HAART, and having received mono- or dual-nucleoside therapy before starting HAART.

RESULTS

During the first 2 years of HAART, HIV-1-infected children experienced a significant increase in CD4+ cell percentage and a decrease in viral load (P<.05). During their last 4 years of receiving HAART, we found a significant decrease in viral load but not an increase in CD4+ cell percentage, because the CD4+ cell percentage reached a plateau after the second year of HAART. Moreover, children with CD4+ cell percentages of <5% at baseline did not achieve CD4+ cell percentages of >25% after 6 years of HAART. Children with CD4+ cell percentages of 5%-25% at baseline had a strong negative association with achieving CD4+ cell percentages of >30% for at least 6 and 12 months but not with achieving CD4+ cell percentages of >30% for at least 24 months.

CONCLUSIONS

Long-term HAART allowed for restoration of CD4+ cell counts and control of viral loads in HIV-1-infected children. However, initiating HAART after severe immunosuppression has occurred is detrimental for the restoration of the CD4+ cell count.

Viral dynamics after starting first-line HAART in HIV-1-infected children

BACKGROUND

After starting HAART, the plasma HIV-1 RNA (pVL) declines rapidly to undetectable levels in most treated adults and children. The viral dynamics in children are assumed to differ from those in adults. Therefore viral decay and time to reach a pVL of < 400 copies/ml during the first weeks after starting HAART were studied in a cohort of HIV-1-infected children.

METHODS

Viral decay expressed as half-life and time to reach a pVL of < 400 copies/ml in 39 HIV-1-infected children starting HAART were calculated and correlated with age, pretreatment with antiretroviral mono- or duo-therapy, and baseline pVL.

RESULTS

Baseline pVL correlated with age (r, -0.41; P = 0.01). Median half-life of the virus was 2.1 days (interquartile range, 1.8-3.0 days). No correlation was found between the half-life of the virus and the baseline pVL at the start of treatment, antiretroviral pretreatment or age. Eight children did not reach a pVL of < 400 copies/ml with the first allocated medication regimen. These children were significantly younger than those in whom HIV was successfully suppressed (P = 0.009). The remaining 31 children reached a pVL of < 400 copies/ml in a median of 8.1 weeks after the start of therapy; time to reach a pVL of < 400 copies/ml was only correlated with baseline pVL.

CONCLUSIONS

These results suggest that pVL at baseline correlated with age. HAART was able to suppress pVL below the lower limit of detection in children with a viral decay rate of 2.1 days, similar to adults and irrespective of baseline pVL.

Virologic, immunologic, and clinical benefits from early combined antiretroviral therapy in infants with perinatal HIV-1 infection

OBJECTIVE

To investigate the impact of early versus deferred combined antiretroviral treatment (ART) in asymptomatic or moderately symptomatic [Centers for Disease Control and Prevention (CDC) category N, A or B] infants with perinatal HIV-1 infection.

METHODS

A multi-centre nationwide case-control study was conducted. Data from 30 infants treated with combined ART with three or more drugs before 6 months of age were compared with data from 103 infants starting ART with three or more drugs after 6 months of age. The median follow-up time was 4.1 years (range, 1.0-6.5 years).

RESULTS

No difference was evident in the first available viral load and CD4 T-lymphocyte percentage between the two groups of children. Early-treated infants showed significantly lower viral loads than infants receiving deferred treatment at all the follow-up periods. A higher proportion of early-treated infants than infants receiving deferred treatment (73.3% versus 30.1%; P < 0.0001) reached an undetectable viral load. Higher CD4 T-lymphocyte percentages were found in early-treated infants at 13-24 (P < 0.0001), 25-36 (P < 0.0001), and 37-48 (P = 0.003) months of age. No early-treated infant versus 20 of 103 (19.4%) infants receiving deferred ART (P = 0.02) showed a CD4 T-lymphocyte percentage of less than 15% at one time point during follow-up. No CDC category A, B or C clinical event occurred in early-treated infants over the follow-up period while 44 of 103 (42.7%) infants receiving deferred treatment presented a decline in the CDC category. Kaplan-Meier analyses revealed significant differences in CDC category A (P = 0.0002), B (P = 0.0003), and C (P = 0.0018) event-free survivals.

CONCLUSION

The data suggest virologic, immunologic, and clinical benefits from early administration of ART.

Use of total lymphocyte count for informing when to start antiretroviral therapy in HIV-infected children: a meta-analysis of longitudinal data

BACKGROUND

Total lymphocyte count has been proposed as an alternative to the percentage of CD4+ T-cells to indicate when antiretroviral therapy should be started in children with HIV in resource-poor settings. We aimed to assess thresholds of total lymphocyte count at which antiretroviral therapy should be considered, and compared monitoring of total lymphocyte count with monitoring of CD4-cell percentage.

METHODS

Longitudinal data on 3917 children with HIV infection were pooled from observational and randomised studies in Europe and the USA. The 12-month risks of death and AIDS by most recent total lymphocyte count and age were estimated by parametric survival models, based on measurements before antiretroviral therapy or during zidovudine monotherapy. Risks were derived and compared at thresholds of total lymphocyte count and CD4-cell percentage for starting antiretroviral therapy recommended in WHO 2003 guidelines.

FINDINGS

Total lymphocyte count was a powerful predictor of the risk of disease progression despite a weak correlation with CD4-cell percentage (r=0.08-0.19 dependent on age). For children older than 2 years, the 12-month risk of death and AIDS increased sharply at values less than 1500-2000 cells per muL, with little trend at higher values. Younger children had higher risks and total lymphocyte count was less prognostic. Mortality risk was substantially higher at thresholds of total lymphocyte count recommended by WHO than at corresponding thresholds of CD4-cell percentage. When the markers were compared at the threshold values at which mortality risks were about equal, total lymphocyte count was as effective as CD4-cell percentage for identifying children before death, but resulted in an earlier start of antiretroviral therapy.

INTERPRETATION

In this population, total lymphocyte count was a strong predictor of short-term disease progression, being only marginally less predictive than CD4-cell percentage. Confirmatory studies in resource-poor settings are needed to identify the most cost-effective markers to guide initiation of antiretroviral therapy.

Immunologic function and virologic suppression among children with perinatally acquired HIV Infection on highly active antiretroviral therapy

BACKGROUND

The goal of highly active antiretroviral therapy (HAART) has been to stabilize and reconstitute immune function and suppress viral replication to the greatest degree possible. Suppression of HIV viral replication has been associated with improved long-term and short-term prognosis. Limited data are available on the level of virologic suppression and immune function of pediatric patients followed in clinical settings in the HAART era.

OBJECTIVE

The objective of this study was to assess the level of virologic suppression and immune function in a cohort of children with perinatally acquired HIV infection followed at dedicated HIV specialty care sites.

RESEARCH DESIGN

This study comprised a cohort study of HIV-infected children and adolescents.

SUBJECTS

Study subjects consisted of 263 HIV-positive children (<or=17 years old), on HAART, with at least one outpatient visit and CD4 test recorded in 2001 seen at 4 U.S. HIV primary pediatrics and specialty care sites (2 eastern, 1 southern, and 1 western).

MEASURES

Measures consisted of all plasma HIV-1 RNA levels <or=400 during calendar year 2001.

RESULTS

Two hundred sixty-three patients received HIV-related treatment during 2001, with a mean age of 8.5 years. Sixty-eight percent were black, 54% were females, and the majority (85%) was insured by Medicaid. A total of 28.6% had a class C AIDS diagnosis. A total of 23.5% and 34% of patients maintained viral suppression at <50 copies per milliliter (cpm), or <400 cpm, respectively, for the calendar year; 32.5% and 38.8%, respectively, fulfilled the criteria if one "blip" to <5000 cpm was allowed. Forty-eight percent maintained all viral loads <5000 cpm, and 74.9% overall had HIV-1 RNAs <or=15,000 cpm. Eighty-seven percent of patients had CD4% >25; only 4.2% had CD4 <15%. Overall, 12.5% of patients had either CD4% <15 or severely decreased absolute CD4 counts (adjusted for age). A total of 4.6% of patients had HIV-1 RNAs >100,000 cpm and severe immunosuppression. Patients who were less likely to achieve virologic suppression to <400 cpm included those with CD4 count <200 cells/mm(3) (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.007-0.46), those with AIDS (OR, 0.5; 95% CI, 0.28-0.94), and those with moderate (OR, 0.42; 95% CI, 0.22-0.79), or severe immunologic suppression (OR, 0.14; 95% CI, 0.046-0.43) based on CD4%.

CONCLUSION

In this multisite, pediatric cohort, the rate of near-complete virologic suppression (<50 or <400 cpm) was low. However, the majority of patients have near-normal CD4 counts and viral loads <15,000 cpm. Follow up will be critical to assess the implications of ongoing low-level viral replication with near-normal CD4 values.

Hospital and Outpatient Health Services Utilization Among HIV-Infected Children in Care 2000–2001

BACKGROUND

The aging of the pediatric HIV cohort and advances in antiretroviral therapy for children may have resulted in recent changes in patterns of healthcare utilization.

OBJECTIVES

The objectives of this study were to examine inpatient and outpatient HIV-related health service utilization in a multistate sample of HIV-infected children, and to assess sociodemographic and clinical correlates of utilization.

DESIGN

Cohort study of pediatric patients with HIV. Demographic, clinical, and resource utilization data were collected from medical records for 2000 and 2001.

SETTING

This study was conducted at 4 U.S. HIV primary pediatric and specialty care sites in different geographic regions.

PATIENTS

Three hundred three HIV-positive children with at least one outpatient visit or CD4 test in either 2000 or 2001 were studied.

MAIN OUTCOME MEASURES

Mean outcome measures were number of hospital admissions, mean length of hospital stay, and number of outpatient clinic/office visits.

RESULTS

Hospitalization rates decreased significantly from 39.2 (95% confidence interval [CI], 28.4-50.1) to 25.3 (95% CI, 16.4-34.3) admissions per 100 patients between 2000 and 2001. Hospitalizations were higher among patients with greater immunosuppression, those 2 years and under, and those with AIDS, but were not significantly related to receipt of highly active antiretroviral therapy. Mean outpatient visits did not change significantly between 2000 and 2001 from 9.09 (95% CI, 8.3-9.9) to 9.06 (95% CI, 8.4-9.7) visits per child per year. Children 2 years and under, those on highly active antiretroviral therapy, those with AIDS, and those with Medicaid had significantly higher outpatient utilization. Those with higher HIV-1 RNA had higher outpatient utilization than those with less advanced disease.

CONCLUSION

Inpatient utilization significantly decreased between 2000 and 2001, but outpatient utilization did not change over time. Compared with prior studies, utilization rates appear to be declining over time. Unlike adults, racial/ethnic or gender disparities in healthcare utilization are less pronounced for HIV-infected children.

Predictors of immunologic long-term nonprogression in HIV-infected children: implications for initiating therapy

BACKGROUND

Early markers that predict immunologic long-term nonprogression in infants with perinatally acquired HIV infection might assist in subsequent antiretroviral treatment decisions.

OBJECTIVES

We sought to identify early markers of immunologic long-term HIV disease nonprogression.

METHODS

We analyzed immunologic and virologic characteristics at 1 and 2 months of age in HIV-infected children who were enrolled in the Women and Infants Transmission Study and born before 1995, comparing immunologic long-term nonprogressors (ILTNPs; n = 10) with non-ILTNPs (n = 127). ILTNPs were children who survived to 8 years or older with CD4 percentages of 25% or greater and counts of 500 cells/mm 3 or more without receiving highly active antiretroviral therapy. Non-ILTNPs were defined as all other HIV-infected children. Receiver operating characteristic curve analysis was used to assess combined sensitivity and specificity for each of these characteristics and to determine potential threshold values to discriminate between ILTNPs and non-ILTNPs.

RESULTS

Characteristics in the first 2 months of life associated with ILTNP status in univariate analysis included higher CD4 percentages, lower CD8 + percentages, lower CD8 + HLA-DR + percentages, and lower HIV-1 RNA PCR values. In receiver operating characteristic analysis CD8 + HLA-DR + percentage had the best combined sensitivity and specificity for discriminating between ILTNPs and non-ILTNPs. CD8 + HLA-DR + percentages of 5% or less predicted ILTNP status with 80% sensitivity and 80% specificity. In multivariate analysis CD8 + HLA-DR+ percentage of 5% or less remained a significant predictor of ILTNP status after adjusting for CD3 + CD4 + percentage and HIV-1 RNA PCR value (odds ratio, 15.4; 95% CI, 1.9-124.7).

CONCLUSION

CD8 + HLA-DR + T-lymphocyte percentage of less than 5% at 1 to 2 months of age might be predictive for ILTNP status but should not be used at this time to make treatment-deferral decisions. Immune activation in HIV-infected infants might herald more disease progression. Further study of the use of this subpopulation in early infancy to predict ILTNP status is warranted.

Recomendaciones CEVIHP/SEIP/AEP/PNS respecto al tratamiento antirretroviral en niños y adolescentes infectados por el VIH

OBJECTIVE

To update antiretroviral recommendations in antiretroviral therapy (ART) in HIV-infected children and adolescents.

METHODS

Theses guidelines have been formulated by a panel of members of the Plan Nacional sobre el SIDA (PNS) and the Asociacion Espanola de Pediatria (AEP) by reviewing the current available evidence of efficacy, safety, and pharmacokinetics in pediatric studies. Three levels of evidence have been defined according to the source of data: Level A: randomized and controlled studies; Level B: Cohort and case-control studies; Level C: Descriptive studies and experts' opinion.

RESULTS

When to start ART should be made on an individual basis, discussed with the family, considering the risk of progression according to age, CD4 and viral load, the ART-related complications and adherence. The ART goal is to reach a maximum and durable viral suppression. This is not always possible, even with clinical and immunologic improvement. The difficulties of permanent adherence and side-effects are resulting in a more conservative trend to initiate ART, and to less toxic and simpler strategies. Currently, combinations of at least three drugs are of first choice both in acute and chronic infection. They must include 2 NA 1 1 NN or 2 NA 1 1 PI. ART is recommended in all symptomatic patients and, with few exceptions, in all infants in the first year of life. Older asymptomatic children should start ART according to CD4 count, especially CD4 percentage, that vary with age. Despite potent salvage therapies, it is common not to reach viral undetectability. Therapeutical options when ART fails are scarce due to cross-resistance. The cause of failure must be identified. Occasionally, there exists clinical and/or immunological progression, and a change of therapy with at least two new drugs still active for the patient, is warranted with the aim of increasing the CD4 count to a lower level of risk. Toxicity and adherence must be regularly monitored. Some aspects about post exposure prophylaxis and coinfection with HCV or HBV are discussed.

CONCLUSIONS

A higher level of evidence with regard to ART effectiveness and toxicity in pediatrics is currently available, leading to a more conservative and individualized approach. Clinical symptoms and CD4 count are the main determinants to start and change ART.

Orofacial disorders in children with HIV disease

The most common orofacial disorders found among HIV-infected children are oral candidiasis, parotid gland enlargement, lymphadenopathy, and oral dryness. These changes are strongly related to immune suppression, immune deterioration, and HIV disease progression. The classification of oral lesions in pediatric patients needs to be updated to reflect the relationship between immunologic and virologic markers.

Early versus deferred antiretroviral multidrug therapy in infants infected with HIV type 1

BACKGROUND

The clinical impact of early antiretroviral multidrug therapy on the risk of early-onset severe human immunodeficiency virus (HIV) disease has not been evaluated on a large scale.

METHODS

We evaluated the risk of early-onset events associated with acquired immunodeficiency syndrome (AIDS), particularly the risk of encephalopathy, among infants in the French Perinatal Cohort, according to whether antiretroviral multidrug therapy was initiated before or after the age of 6 months.

RESULTS

Of 83 HIV-infected infants born in 1996 (when HAART became available) or later, 40 received early treatment on or before the age of 6 months, and 43 received deferred multidrug therapy after the age of 6 months. In the group that received early multidrug therapy, no child developed an opportunistic infection or an encephalopathy during the first 24 months of life. In the deferred multidrug therapy group, 6 infants presented with a total of 7 AIDS-associated events (P=.01), 3 of which were encephalopathies (P=.08). The small number of events prevented the identification of clinical and biological markers that accurately predict progression of early-onset severe HIV disease.

CONCLUSION

In this observational study, infants who received multidrug therapy before 6 months of age did not have the early-onset severe form of childhood HIV disease. Further studies are needed to find accurate early markers of disease progression in this age group.

Response to highly active antiretroviral therapy varies with age: the UK and Ireland Collaborative HIV Paediatric Study

OBJECTIVE

To evaluate the effect of age, CD4 percentage (CD4%) and plasma HIV-1 RNA on response to highly active antiretroviral therapy (HAART) in previously untreated children.

DESIGN

Cohort study.

METHODS

We examined the association between age at HAART initiation, and CD4 and HIV-1 RNA response using logistic and Cox regression, adjusting for sex, route of infection and pre-HAART values.

RESULTS

CD4% increases of > 10% at 6 months were more likely in younger children [odds ratio (OR), 0.84 per year, P < 0.001] and those with lower pre-HAART CD4% (OR, 0.67 per 5% higher, P < 0.001), but were not related to pre-HAART HIV-1 RNA (P = 0.6). In contrast, HIV-1 RNA suppression < 400 copies/ml at 6 months was more likely in older children (OR, 1.09 per year, P = 0.03), and was unrelated to pre-HAART HIV-1 RNA or CD4% (P > 0.3). CD4% was still increasing during the second year following HAART initiation (60% followed > 24 months). Longer-term increases in CD4% occurred faster, and decreases in HIV-1 RNA occurred more slowly in younger children. The median time to CD4% >/= 30% after initiating HAART with CD4% </= 25% was under 12 months for children under 2 years irrespective of pre-HAART CD4%, and increased progressively in older children and as CD4% decreased.

CONCLUSIONS

Children respond immunologically to HAART irrespective of pre-HAART HIV-1 RNA or clinical status. However, immunological response is better in younger children and those with lowest CD4%, whereas younger children have poorer virological response, increasing the risk of resistance. Differences in response to HAART according to age and underlying risk of disease progression should be considered when initiating HAART in children.

PENTA guidelines for the use of antiretroviral therapy, 2004

There have been few major advances in paediatric HIV management over the last 2 years. Decisions about starting antiretroviral therapy can now be based on a recent large meta-analysis of the predictive value of CD4 and HIV RNA viral load (VL) in nearly 4000 untreated children, which is discussed in these updated guidelines. Risk estimates for progression to AIDS and death using surrogate markers can now be broken down by age, allowing more accurate discussion with families. In addition, there is increasing recognition of the problems of long-term adherence, drug resistance and cumulative toxicity in adults and children. The controversy over whether to treat asymptomatic infants continues. For older children more data on the efficacy of ritonavir boosted protease inhibitor (PI) regimens suggests that these may be the PI option of first choice. There is still no adult or paediatric trial evidence on which to base decisions about whether to start with PI- or non-nucleoside reverse transcriptase inhibitor (NNRTI)- based regimens, but the PENPACT 1 trial, which is addressing this question, is ongoing. There are increasing moves to provide simpler antiretroviral therapy (ART) regimens, including once daily dosing, but these lag behind adult regimens because of the paucity of pharmacokinetic data. Resistance assays should now be performed in all HIV-infected infants exposed to ART in pregnancy. Therapeutic drug monitoring may be very important in children because of high between- and within-child variability in drug absorption and metabolism. A trial to evaluate this should start shortly in Europe (PENTA 14 trial). The value of resistance tests for choice of second-line and subsequent choices of ART regimens remain unproven (the PERA trial will report late in 2004), but resistance assays are increasingly being used. The issue of when to switch therapy also remains unanswered and is being addressed within the PENPACT 1 trial. Regular formal assessment of adherence is now the standard of care, and routine monitoring in the clinic for lipodystrophy syndrome (LDS) and other ART toxicities is increasingly important. These guidelines will be updated again in 2006.

A trial of three antiretroviral regimens in HIV-1-infected children

BACKGROUND

Depletion of CD4 T-cell counts or progression of human immunodeficiency virus (HIV) disease occurs rapidly in children, but few data address the efficacy of aggressive therapy for HIV-infected children.

METHODS

We evaluated the safety, tolerability, and activity of three regimens of antiretroviral therapy in a multicenter, open-label, phase 1-2 trial. Children infected with HIV type 1 (HIV-1) were stratified at entry according to age--three months or younger (early therapy) or older than three months (delayed therapy)--and assigned sequentially to one of three regimens. Children continued to receive treatment for up to 200 weeks if the plasma HIV-1 RNA level was less than 1000 copies per milliliter by 16 weeks.

RESULTS

Plasma HIV-1 RNA levels fell from a median of 5.3 log copies per milliliter (range, 3.3 to 6.4 log copies per milliliter) at baseline to less than 1000 copies per milliliter at 16 weeks in 32 of 52 infants (62 percent). Plasma HIV-1 RNA levels were below 400 copies per milliliter at 48 weeks in 26 infants (50 percent) and at 200 weeks in 23 infants (44 percent). An intention-to-treat analysis revealed that significantly more children who received stavudine, lamivudine, nevirapine, and nelfinavir had plasma HIV-1 RNA levels of less than 400 copies per milliliter at 48 weeks (83 percent) and 200 weeks (72 percent) than children who received reverse-transcriptase inhibitors alone (P=0.001 and P=0.01, respectively). Fewer infants in the delayed-therapy group than in the early-therapy group (30 percent vs. 60 percent) had plasma HIV-1 RNA levels of less than 400 copies per milliliter at 200 weeks (P=0.03). Treatment-associated adverse effects were infrequent.

CONCLUSIONS

In this phase 1-2 trial involving HIV-1-infected children, an age of three months or younger at the initiation of therapy and treatment with stavudine, lamivudine, nevirapine, and nelfinavir were associated with improved long-term viral suppression. Larger, randomized trials are required to define the optimal time to initiate therapy and the optimal regimen for these infants.

[Update on antiretroviral treatment in HIV infection]

In recent years, major advances have been made in the care of HIV-infected children, particularly in antiretroviral treatment, which have dramatically improved survival and quality of life. The goal of highly active antiretroviral therapy (HAART), which includes at least three potent drugs, is the maximal and most durable suppression of viral replication possible, which is often not achieved despite clear immunologic and clinical improvement. There are still major barriers to achieving this goal, mainly the difficulty of permanent adherence to complex regimens and treatment-related toxicities. Adverse events are frequent, including a high prevalence of metabolic complications with unknown consequences in the future. These drawbacks of antiretroviral treatment are leading to a more conservative initial approach, as well as to research into simpler and less toxic therapeutic options. New strategies should continue to be developed to overcome the still important limitations of current antiretroviral treatment.

Gender and race do not alter early-life determinants of clinical disease progression in HIV-1 vertically infected children

OBJECTIVE

To identify early life predictors of clinical progression before and beyond age 1 year.

DESIGN

Prospective follow-up of 161 vertically HIV infected children in the ongoing European Collaborative Study provided data from birth over 16 years.

METHODS

Kaplan-Meier and Cox regression procedures were used to assess the predictive value of first available laboratory and clinical markers for progression defined as serious disease or death. We investigate gender and race effects on associations and the optimal threshold for longitudinal CD4+ percentage measurements after age 6 months for predicting disease progression.

RESULTS

Earliest (during the first 6 months) measurements of CD4+ percentage below 20% [three-fold increased risk (P = 0.041)] and absolute lymphocytes (AL) (reduction of risk of three-quarters for a one log increase (P =0.014)) were independently associated with overall and rapid disease progression during the first year. Persistent lymphadenopathy (or hepatomegaly) in early life was also additionally associated with overall disease progression, and after age 1 year [greater than doubling of risk, (P = 0.040)], but not with rapid progression. Associations were not significantly dependent on gender or race. CD4+ percentage of 10% was the best prognostic cut-off.

CONCLUSIONS

Early clinical markers are strongly predictive of disease progression after 1 year of age into adolescence. However, rapid progression is less straightforward to predict, probably due largely to early progression during the first few months in such individuals. The independently predictive value of AL measurements suggest they could be used alone in the management of children in resource-poor settings.