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Review
. 2014 Jan;9(1):87-94.
doi: 10.1097/COH.0000000000000027.

Immediate antiretroviral therapy in young HIV-infected children: benefits and risks

Intira J Collins  1 , Ali Judd, Diana M Gibb
Affiliations
Free PMC article
Review

Immediate antiretroviral therapy in young HIV-infected children: benefits and risks

Intira J Collins et al. Curr Opin HIV AIDS. 2014 Jan.
Free PMC article

Abstract

Purpose of review: Recent WHO guidelines recommend immediate initiation of lifelong antiretroviral therapy (ART) in all children below 5 years, irrespective of immune/clinical status, to improve access to paediatric ART. Interim trial results provide strong evidence for immediate ART during infancy because of high short-term risk of mortality and disease progression, but there is wider debate regarding the potential risks and benefits of immediate ART in asymptomatic children aged above 1 year. Concerns include long-term toxicities and treatment failure, particularly in resource-constrained settings with limited paediatric treatment options.

Recent findings: Benefits of immediate ART among infants appear to be maintained in the mid-term to long-term, with low risk of treatment failure, and better neurodevelopmental outcomes. In contrast, a trial reported no benefits of immediate versus deferred ART in asymptomatic children aged above 1 year. However, observational studies suggest that ART initiation at older ages and lower CD4 reduces the probability of immune reconstitution, with unclear implications on risk of clinical events or treatment change. A recent trial on treatment interruption following early intensive ART suggest that this may be a safe alternative approach.

Summary: Although there are clear benefits of immediate ART among infants, there remains conflicting evidence on the benefits for older children.

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References

    1. UNAIDS: a progress report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive; 2012. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspubl... [Accessed 26 February 2013]
    1. World Health Organization/UNICEF/UNAIDS WH: Global Update on HIV Treatment 2013: Results, Impact and Opportunities. 2013. http://apps.who.int/iris/bitstream/10665/85326/1/9789241505734_eng.pdf [Accessed 14 February 2013]
    1. UNAIDS: 2013 Progress Report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. 2013. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspubl... [Accessed 15 September 2013]
    1. Newell M-L, Coovadia H, Cortina-Borja M, et al. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 2004; 364:1236–1243 - PubMed
    1. Becquet R, Marston M, Dabis F, et al. Children who acquire HIV infection perinatally are at higher risk of early death than those acquiring infection through breastmilk: a meta-analysis. PLoS One 2012; 7:e28510. - PMC - PubMed

    2. A large pooled analysis of over 12 000 children, which showed poorer survival in perinatally infected as compared to postnatally infected children without ART.

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